9TH World Congress Of Endoscopy Surgery - edigraphic.com

Artículo:
Revista Mexicana de Cirugía Endoscópica
Volumen
Volume 5
Resúmenes de Trabajos Libres y Video
del V-99 a FP-167
Otras secciones de
este sitio:
☞ Índice de este número
☞ Más revistas
☞ Búsqueda
Suplemento
Supplement
1
Febrero
February 2004
Derechos reservados, Copyright © 2004:
Asociación Mexicana de Cirugía Endoscópica, AC
Others sections in
this web site:
☞ Contents of this number
☞ More journals
☞ Search
edigraphic.com

V-99
VIDEOTHORACOSCOPIC RESECTION OF AN ESOPHAGEAL DI-
VERTICULUM
Targarona EM, Canalis E, García A, Rey A, Trias M. Serv of Surgery,
H. St. Pau & Serv Thoracic Surgery, H. Clinic, Centro Medico Teknon,
Barcelona, Spain.
Mid and low third pulsion esophageal epiphrenic diverticula require
surgical treatment. Yuxta cardial diverticula can be approached by
a trans hiatal approach, but higher situation requires a thoracic
approach. Case report: A 52 year Old man complaining of severe
pirosis and thoracic pain oesophagogastric Rx series showed a
hiatal sliding hernia, oesophagogastric reflux and a 5 cm. Esophageal
diverticulum located in the upper part of the lower third of
the esophagus. Manometry ruled out the existence of a motor disturbance
and a pathologic ph-metry. The patient was approached
trough the abdomen, an a transhiatal dissection was tried but the
diverticula was too high for a safe resection, and a crural closure
and Toupet partial plication was done. The GERD symptoms disappeared
but thoracic pain persisted, and 3 months later, a
videothoracoscopic resection of the diverticulum was proposed. The
right thorax was approached through a 5 cm minithoracotomy and
two 5 mm trocars. The diverticulum was located at the mid-lower
third union of the oesophagus. Dissection permit to clearly view
the neck of the sac, and transection with mechanical suture (Surg
Assist) was done. Staple line was reinforced with esophageal muscular
closure and a chest drain was placed. Esophagogram three
days later ruled out the existence of leakage, and the patient was
discharged at the 5 th postoperative day.
FP-100
LONG TERM OUTCOME OF LAPAROSCOPIC HELLER’S MYO-
TOMY WITHOUT AN ANTI REFLUX PROCEDURE
Gupta R, Sample C, Bamehriz F, Brich D, Anvari M.
Addition of anti-reflux procedure to a Heller’s myotomy has been
a contentious area. The aim of this study was to evaluate long
term outcome of laparoscopic Heller’s myotomy (LHM) without
anti reflux procedure. Method: We reviewed 40 patients (21F:19M)
with mean age of 44.9 ± 17.2 years with a diagnosis of achalasia
who underwent LHM without antireflux procedure at our institution
from 1993 to 2003. Of these, twelve patients had botulinum
toxin (botox) injection (2.8 per patient) and fourteen patients had
pneumatic dilatation (mean 1.9 per patient) prior to surgery. Results:
LHM was completed in all of the patients with mean OR
time of 79.2 ± 28.7 min OR time was significantly increased in
patients with pre-operative botox injections (98.3 vs 71.1 min, p =
.005). There were 4 intra-operative complications (mucosal injury
in 3, hemorrhage in 1). Two patients with mucosal injury had
pre-operative injection of the LES with botox. Mean hospital stay
was 1.9 d ± 0.95 (range 1 to 5 days). After a mean follow up of
44.6 ± 31.2 months mean dysphagia score improved significantly
(p = .001) from 11.1 + 1.7 pre op. to 0.2 + 1.3 post op. and was
associated with a significant (p = .001) decrease in LES pressure
from a mean of 29.6 ± 15.6 (pre op.) to 6.3 + 6.8 (post op.) 2
patients (5%) developed dysphagia later on requiring reoperation
(one open, one laparoscopic). The mean heart burn score
did not change significantly from 3.7 + 4.4 pre op. to 3.2 ± 4.3
post op. which was confirmed by pH study in 19 patients with a
mean % acid reflux of 3.4 ± 4.3 pre and 3.3 ± 4.9 post op. 32
patients had excellent control of reflux on acid suppression medications
and 8 patients did not require any medication. Conclusion:
Our experience with LHM indicates excellent overall clinical
outcomes without an antireflux procedure.
FP-101
LAPAROSCOPIC CHOLECYSTECTOMY WITH ONLY ONE PORT
Dávila F, Montero JJ, Dávila U, Lemus J. Department of Surgery.
Pemex Hospital and Fausto Davila Solis Hospital, Poza Rica, Veracruz,
México.
Abstract Book
edigraphic.com
29
Our surgical group makes endoscopic cholecystectomy with technique
of an umbilical port since 1997. We have integrated other procedures
with this technique like: appendectomy, hysterectomy, ovarian
cystectomy, inguinal hernia repair. The purpose of this study is
to prove that this technique is a viable choice in gallbladder surgery.
Design: Transversal, prospective study. A thousand patients were
examined from december 1997 to april 2003, such patients presented
symptoms of gallbladder disease and needed to take them into
surgery. Five hundred group A patients got traditional laparoscopic
cholecystectomy. Five hundred group B patients got laparoscopic
cholecystectomy with only one port. We analyzed the following variable:
age, gender, hospitalization time, surgical time, failures or conversions,
cost and cosmetic. We used Student’s t-test for comparison
of variables and χ 2 test for percentages. Cholecystectomy with
only one port supports the uses of percutaneous needles. There were
no differences; neither in age or gender nor the hospital permanence.
The average in the surgical time, in Group A, was 78 minutes and
group B, 88 minutes (P < 0.05). The conversions to open cholecystectomy
were 4% in both groups. However, in group B, there was
also a conversion to traditional laparoscopic cholecystectomy in 14%.
Group A used two ports of 5 mm and two ports of 12 mm. Group B
used 1 port of 12 mm, relation 4 to 1 ports. We conclude that cholecystectomy
of only one port is applicable in 82% (P < 0.01) of the
patients with gallbladder disease. It improves the aesthetic results
and it provokes an excellent psychological effect in the patients for
acceptance of this surgery, and reduces costs, too.
V-102
RETAINED COMMON BILE DUCT STONES. LAPAROSCOPIC
TREATMENT AFTER ENDOSCOPIC FAILURE
Antozzi M, Zueedyk M, Signoretta A, Camicia G, Moro M. Hospital
Italiano Regional del Sur, Bahía Blanca, Argentina.
Purpose: Consider the laparoscopy like a therapeutic option in the
retained common bile duct stones after failure of endoscopic procedure.
Methods: 69 years old female, cholecystectomy 10 years previous.
Presented obstructive jaundice with acute cholangitis caused by
retained common bile duct stones five years after surgery; with a good
response to the medical and endoscopy treatment. Five years later
repeated a new episode, but it was not possible endoscopic extraction
of multiple stones, 2 cm average diameter. Laparoscopic approach
was performed. Results: Laparoscopy, adhesiolysis, choledochotomy
with choledocholithotomy, later lateral choledochoduodenum anastomosis
and abdominal drainage were done. Remove it at 72 hours.
Follow up at 22 months with normal clinical, biochemical and ultrasonography
controls. Conclusions: Treatment of retained common
bile duct stones by laparoscopy is possible. For that reason it has to
be considered after the failure of endoscopic procedure.
V-103
DIFFICULT LAPAROSCOPIC CHOLECYSTECTOMY RISK AND
BENEFITS
Contreras AA, Lozada LJD, Nava AD, Abunez PA, Carreto AF. Santa
Mónica Hospital, Cuernavaca Morelos, México.
Purpose: The objective of this video is to present some difficult laparoscopic
cholecystectomy in which it is very important to make to
good decision if continue the surgery in laparoscopic fashion or decides
to convert to and open technique. Material and methods: In
a period of two years 72 have been operated of laparoscopic
cholecystectomy, in patients with rank of age of 14 to 92 years old
with median average of 63 years old, 40 women (55.5%) and 32
men (44.4%), 20 patients (27.7%) were operated emergency by
acute gallbladder cholecystitis, 9 patients with hydrocholecystis, 6
patients with pyocholecisto, 4 patients with hydrocholecystitis and
choledocolithiasis, two patients with pyocholecisto and biliary pancreatitis,
a patient with gallbladder cancer, being necessary to turn
to single conventional surgery a patient to straight detect during
the surgical procedure a biliary leakage by laceration with the endoshears
of the right hepatic duct. Results: Of our cases considered
like difficult gallabladder was not necessary to convert to open

9 TH World Congress of Endoscopic Surgery
surgery none, the patient who had itself to turn to conventional surgery
was a patient in whom we identified a biliary leakage of the
right hepatic duct by a small laceration during the dissection, just in
the bifurcation of both hepatic duct, reason why we decided to convert
open surgery and biliary exploration, I am located the site of
laceration and 4 stich with prolene vascular 5-0 I put in placed a
cattle 16 Fr, in the immediate postoperatively the fistula continue
drainage in 24 hours 300 ml, we being rich enteral feeding in arginina
and glutamina, persisting the leakage for two weeks, without
changes, we decided to make ERCP and Endoscopic Sphincteromy
and positioning of biliary endoprosthesis, with good results,
the leakage decreases to 0 millimeter at the 8 th day, being able to
retire of catell tube to the two weeds after endoscopic procedure.
Conclusions: Difficult cholecystectomy is a subjective TERM that!
Depends on the degree of surgical laparoscopic skill of the surgeon
and his surgical team, but whenever it is not possible to continue in
the laparoscopic fashion it is necessary to think about turning the
procedure to conventional surgery by security of the patient.
FP-104
CAN WE PREVENT BILE LEAKS AFTER LAPAROSCOPIC CHOLE-
CYSTECTOMY?
Hamouda A, Khan M, Mahmud S, Nassar AHM.
The incidence of post-cholecystectomy bile leakage (PCBL), without
bile duct injury, is 0.8-2%. Published studies have addressed the sources,
mainly cystic duct stump and subvesical duct leaks, and their
management. As endoscopic, laparoscopic or laparotomy reintervention,
have obvious disadvantages, how can this complication be prevented?
Aims and methods: To study the possible aetiological mechanisms
and the methods of preventing PCBL, prospective data from
a large series of LC performed on one firm was analyzed. Dissection
techniques and methods of securing the cystic duct and subvesical
ducts were evaluated. Results: Subvesical ducts were encountered
in 22 of 1,260 cases of LC (1.7%). Nine were secured with loops,
seven were ligated and six were sutured. In our practice, Calot triangle
and gallbladder dissection is carried out using only a blunt dissecting
forceps with flat jaws, the so called “duckbill”. This is used to
open windows in the peritoneal reflection and the jaws open to create
a plain. Sweeping the gallbladder wall away from the liver makes it
possible to identify any accessory ducts before using diathermy. It is
very likely that hook dissection would have caused some to leak, as
the hook may transect or open accessory duct without identifying them,
coagulating the open ends at the same time. This may explain the
delay of 2-5 days in most reported series until necrosis and sloughing
occur causing leakage. Only one case of asymptomatic bile leakage
requiring reintervention was encountered (0.08%). The patient had
dense adhesions obscuring the cystic pedicle, necessitating fundus –
first dissection. The pedicle was thickened and short and the cystic
duct and artery could not be separated. Two endoclips were applied.
A subphrenic drain produced 500 mls of bile for 3 days and ERCP
showed a cystic duct leak and a “fingerscrossed” appearance of the
endoclips which had twisted due to the thickening of the pedicle. A
stent was inserted, the leakage stopped and the total hospital stay
was 6 days. The stent was removed six weeks later. Following this,
endoclips were abandoned in favour of intracorporeal ligation of the
cystic duct and artery. No postcholecystectomy was encountered in
the last 850 cases. Conclusion: In spite of its considerable benefits,
the laparoscopic era has brought about some practices alien to conventional
surgical principles. Using diathermy hooks for dissection and
metal clips to occlude structures which used to be ligated and the
explosion in the use of ERCP to investigate and treat suspected choledocholithiasis
are but a few examples. Our techniques helped us to
avoid a potential PCBL rate of 1.7%. Active search for subvesical
accessory duct can reduce the incidence of post-operative bile leaks.
Avoiding the use of endoclips and diathermy hooks may help to prevent
this complication.
V-105
LAPAROSCOPIC TREATMENT OF BILE DUCT ASCARIDIASIS
Serrano J.
edigraphic.com
30
Ascaris are round worms that live in the human small bowel. The parasites
eggs are eliminated with feces and infected the new host with
the food. The egg covering is destroyed in the duodenum and the
larva goes throught the small bowel wall to the liver and lungs, go up
the traquea and to the small bowel were they live. The infected patient
present tipically an abdominal pain, but it could also produce an
intestinal obstruction by pilled up, appendicitis or bile obstruction with
colangitis or liver perforation. The diagnosis of bile ducts ascaridiasis
is made by ultrasound, in some cases by ERCP. The bile ducts ascariasis
treatment is made with a antiparasite drugs. When there is no
good response, we can try the parasite extraction by endoscopy. If
that procedure fails the surgical treatment is recommended, with the
laparoscopic extraction of the parasite. The bile duct ascaridiasis frequency
in our state was 8 to 12 %. The actual reports in Ecuador
shows a rate from 5 to 7 %. On my personal experience, I have four
patients in a total of 600 lap-choles, it represent a 0.66% of the biliar
pathology. The video presents the technique of laparoscopic exploration
of the common bile duct, the extraction of the parasite and the
cholecystectomy.
V-106
HEPATOBILIARY PATHOLOGY DUE TO ASCARIS LUMBRI-
COIDES. LAPAROSCOPIC RESOLUTION
Astudillo MR, Astudillo CA.
In our country ascaris lumbricoides is still an important surgical pathology,
and between theses the biliary tract and liver pathology. In
Hospital Latinoamericano, Cuenca Ecuador in a 11 year period we
have performed 1,726 laparoscopic procedures for hepatobiliary pathology,
7 patients had common bile duct ascaridiasis. 1 patient has
a liver abscess due to ascaris lumbricoides. We review the different
techniques for the treatment of these pathology (clinically, endoscopically
and laparoscopically) and the one to be used in each case.
FP-107
EXPERIENCE OF LAPAROSCOPIC COMMON BILE DUCT EXPLO-
RATION
Ramirez-Barrantes MM, Soto-Davalos BA, Luna-Martinez J, Del Pozzo-Magaña
JA. General Surgery Resident at the Hospital Central
Sur de Alta Especialidad de PEMEX, Picacho, Mexico City. Attending
physician at the General Surgery ward of the Hospital Central
Sur de Alta Especialidad de PEMEX, Picacho, Mexico City.
Description: Background: Minimal invasive surgery has changed
the surgical standards of our times, it seem logic to perform every
time more laparoscopic procedures. The first open common bile duct
exploration (OCBDE) was performed by Ludwig Courvosier 1889.
Bakes in 1891 was able to look inside of the common bile duct (CBD)
with an instrument of his creation. McLever in 1941 describes the
optic choledochoscope. Jacobs was one of the first surgeons to describe
laparoscopic choledochotomy. Actual data reports that 15%
of patients with gallbladder stones have bile duct stones, for which
reason the laparoscopic procedure is a therapeutic and diagnostic
option, without the disadvantages of the open procedure. The reported
mortality of the laparoscopic CBD exploration (LCBDE) shifts
from 0 to 1% and morbility from 1 to 12% depending on the surgical
approach (transcystic vs laparoscopic choledochotomy). Another
treatment for CBD stones are endoscopic retrograde cholangiography
(ERCP) with a risk of complications such as bleeding (3%),
pancreatitis (2%), duodenal perforation (1%), and late papillotomy
stenosis (10-33%), and OCBDE that increases 3 times the morbility
and has the inconvenience of doing the exploration by hand. LCB-
DE has a reported complication rate of 7% with less surgical trauma
and hospital stay. Purpose: The purpose of this study is to
present the experience of a third level hospital at PEMEX, Mexico
city. Methods: We reviewed 8 cases of randomized patients programmed
for elective surgery in a period of 6 months from November
2002 to may 2003, 6 of which were women and 2 were men,
with ages that range from 46 to 76 years with a median age of 67.
All had a preoperative ultrasound with gallbladder stones, 7 with
suspected CBD stones and 3 had a previous history of pancreatitis.

All patients were operated for laparoscopic cholecystectomy (LC)
and exploration with a choledochoscope was performed: 3 transcystic,
3 with choledochotomy, and 2 were performed with both.
Results: Of 8 patients analyzed 5 had choledochoscopic confirmation
of CBD stones, 4 patients had successful extraction of the stones
(80% of successful clearance), the only patient :rop that odarobale did not FDP had
successful extraction of the CBD stone required of conversion to
OCBDE because of the size VC of ed the AS, stone cidemihparG and adherence to the
CBD wall. The average operative time was 160 min, the postoperative
length of stay ranged from 1 to 15 days (one arap patient had a 15
day stay because of a cause non-related to the procedure of chronic
renal failure) with acidémoiB an average arutaretiL length :cihpargideM
of stay of 4.5 days, none of
the sustraídode-m.e.d.i.g.r.a.p.h.i.c
patients presented hyperamylasemia or pancreatitis in the postoperative
period, the laparoscopic choledochotomy group had a Ttube
inserted without evidence of bile leak and a successful extraction
of the T-tube at the 4th week of the postoperative period, none
of the patients had bile duct injury. The postoperative pain was minimum
(visual analog scale 3/10) that responded to ketorolac dose
of 30 mg 3 times a day for 2 days, feeding was started at 12 hrs
postoperatively with good tolerance in all patients. Minor late complications
consisted in seroma of the umbilical port in an obese
patient and atelectasis that was resolved by respiratory therapy. In
the CBD stone group with successful extraction none presented
retained stones verified by a postoperative cholangiogram. Conclusions:
These data shows that LCBDE decreases the postoperative
rate of retained stones. In our study we had a 100% of visualization
of the proximal and distal CBD and an 80% success rate for
CBD stone extraction. There was no surgical-related morbidity and
0% mortality. No patient was reoperated. The transcystic access
decrease the length of stay (one patient was released at the 24 hrs
of the postoperative period). Our study also shows that the diagnostic
accuracy of ultrasound is less compared with LCBDE with a
choledoscope. The choledochotomy requires more experience and
surgical skills in advanced laparoscopic techniques. We conclude
that LCBDE is a reliable, secure and feasible option in trained hands
with an adequate equipment.
FP-108
CHOLEDOCHORRHAPHY IN THE TREATMENT OF BILIARY LITH-
IASIS FOLLOW-UP 24 MONTHS
Germán N, Mario G, Diego A, Acevedo J, Ramírez IF, Braz MI, Marcelo
G. General Surgery Doctors from Horacio Séller Hospital, Neuquen.
Argentina.
Introduction: The primary closure of the choledocho (PCC), even
though it requires specific technological support, and surgical skills is
considered by many authors the ideal operation for choledocholithiasis.
Material and method: With the aim of analyzing PCC results, in a
retrospective study from July 1999 to October 2000 we have included
all the patients who went through this technique. Results: 18 patients,
with an average of 33.5 years (17 to 59). Fourteen operated by laparoscopy
, two converted, and a PCC with conventional start 93%
effective surgery. Bile duct average by ecography and IOC 10.5 mm.
The average time of operation was 145 minutes. Two patients with
high possibility of mortality, with choleperitoneum and reexploration
(11%). Mortality 0%. Average of stay in hospital 3.3 days and the follow
up average 24 months (10 to 48 months). Conclusions: The technique
offers good results with high level of success and low mortality.
FP-109
LAPAROSCOPIC MANAGEMENT OF CHOLEDOCHOLITHIASIS
Statti M, Minatti W, Pérez CR, Gatti D, Premoli G.
With the advance of laparoscopic techniques becomes possible
the laparoscopic approach as a therapeutic option for the treatment
of common bile duct stones. Design: Retrospective study.
Setting: Private Hospital affiliated to Buenos Aires University. Patients
and methods: All patients with choledocholithiasis that underwent
laparoscopic surgery from January 1995 to December
2000 were included. Age, gender, procedure, morbidity and mortality
were assessed. Results: 207 patients were included. 60%
Abstract Book
edigraphic.com
31
were females with a median age of 71 years old. Twenty patients
underwent preoperative ERCP with posterior laparoscopic cholecystectomy.
Ten patients underwent laparoscopic cholecystectomy
with postoperative ERCP. Seven patients underwent open
surgery, and in 177 patients laparoscopic surgery were carried
out. sustraídode-m.e.d.i.g.r.a.p.h.i.c
Conversion rate was 4%. Procedures carried out in the group
of cihpargidemedodabor
laparoscopic bile duct exploration were: Transcystic exploration,
choledochotomy and choledochoduodenostomy. Mortality
rate was 0.9%. Conclusion: Laparoscopic approach of patients
with choledocholithiasis is feasible and safe. Combined methods
let to resolved all patients.
FP-110
MANAGEMENT OF COMPLICATED BILIARY TRACT DISEASE ON
GASTRIC BYPASS PATIENTS
Podkameni D, Szomstein S, Chousleb E, Villares A, Lomenzo E, Kennedy
C, Zundel N, Rosenthal R.
Section of Minimally Invasive Surgery, The Bariatric Institute, Cleveland
Clinic Florida.
Management of biliary tract disease can pose a challenge to any experienced
surgeon, specially in patients who were submitted to gastric
bypass for treatment of morbid obesity. From our ongoing experience
of 800 patients submitted to Laparoscopic Roux en Y Gastric
Bypass (LRYGBP) we had 3 patients that developed biliary tract complications.
We review their charts and analyze the treatment involved.
Case one was a 44 year-old male who came to the emergency room
after a LRYGBP with complaints of right upper quadrant pain, fever
and jaundice. Twenty years earlier he was submitted to a cholecystectomy.
An MRCP was unattainable due to his ongoing super obesity,
so a decision was made to do a transgastric ERCP (TG-ERCP).
Multiple stones were excreted and an sphincterotomy was performed.
A completion cholangiogram revealed no residual stones. The patient
was discharged home on postoperative day 3 afebrile and pain
free. Second patient was a 38 year-old female who underwent a LRYG-
BP and cholecystectomy. Post operatively she developed a biloma. A
HIDA scan was performed which revealed a bile leak. A TG-ERCP
was then performed. The TG-ERCP had two objectives: to identify
the location of the leak and possible biliary tree decompression. The
CBD was cannulated and a cholangiogram demonstrating an accessory
duct of Luschka was obtained. A stent was placed for biliary decompression.
On postoperative day two the patient was discharged
to home. She came back 5 weeks later to have a new TG-ERCP. The
patient was afebrile symptom free, and had the stent removed. Our
third case was a 24 year-old female that 6 months after being submitted
to a LRYGBP developed acute cholecystitis and concomitant elevation
of alkaline phosphatase. An MRCP revealed presence of CBD
stones. Patient was submitted to an uneventfully laparoscopic cholecystectomy
and CBD exploration through the cystic duct. A completion
cholangiogram revealed no remaining stones. Complications of
surgery on the biliary tract may pose a challenge on itself. This may
be a double challenge if the patient had GBP surgery for morbid obesity.
Surgeons in general need to be resourcefully and aware of different
approaches to deal with biliary tract complications in the bariatric
population submitted to gastric bypass surgery.
FP-111
CAUSES OF FAILURE IN LAPAROSCOPIC GASTRIC BANDING
Lo Menzo E, Podkameni D, Kennedy C, Villares A, Soto F, Higa G,
Chousleb E, Berkowski D, Szomstein S, Rosenthal R. Bariatric Institute
Cleveland Clinic Florida Weston, FL.
Background: Laparoscopic adjustable gastric band is a safe and effective
option for weight loss surgery in selected cases. We present 3
cases of failure of the band requiring re-operation. Methods: The first
case is a 55 year-old man with a history of sleep apnea and a BMI of
44. The patient had an excellent weight loss result of over 100 lbs
(BMI of 30). Unfortunately he developed progressive dysphagia and
heartburn over a 2-year period. Swallow examination revealed worsening
megaesophagus in spite of complete band deflation. The second
case is a 41 year-old man with a BMI of 41 and sleep apnea,

9 TH World Congress of Endoscopic Surgery
who had gastric banding 2 months prior to its removal for erosion.
The patient presented with increasing pain in the left upper quadrant
and night sweats. In spite of negative fluoroscopic and tomographic
evaluations, the endoscopy proved the band erosion. The third case
is a 46 year-old man with hypertension and a BMI of 46 who, 8 months
after his gastric banding, developed dysphagia and vomiting. The
gastrografin swallow confirmed the presence of a slippage and the
band was completely deflated, without resolution of symptoms. Results:
The case of megaesophagus required laparoscopic removal
of the band. At his 4-month follow up the patient has maintained his
initial weight loss. The erosion required laparoscopic removal of the
band, drainage and antibiotic therapy. The slippage was repaired
laparoscopically and the band left in place. Conclusion: Laparoscopic
gastric banding presents some unique complications. Close follow
up and early intervention are required.
FP-112
ENDOSCOPIC MANAGEMENT OF CHOLEDOCHOLITHIASIS IN
PATIENTS OVER 79 YEARS
Staltari JC, Capellino P, Ramos P, Premoli G, Mendiburu A.
Background: Incidence of bile duct stone increases with age of
patients, with highest incidence over 79 years old. This group has
important comorbidities and in some cases contraindication for
surgery. In that cases endoscopic management become the procedure
of choice. The purpose is to analyze endoscopic management
of bile duct stone in patients over 79 years old. Design:
Retrospective study. Setting: Private Hospital associated to Buenos
Aires University. Patients and methods: Patients over 79
years old with bile duct stone managed by endoscopy were analyzed
from January 1995 to January 2001. Age, gender, number
and type of procedure, effectivity, morbidity and mortality were
assessed. Results: Eighty four patients were included, 42 of them
were females. Average age was 83 years old (range: 80-95). In
that group 122 procedures were carried out, 57 patients required
onlyone procedure, 27 patients needed two procedures, 7 patients
required three procedures and 4 patients needed four procedures.
Effectiveness rate was 82.1%. Morbidity related to the procedure
was 13% (15 patients), while mortality was 3.6% (3 patients). Average
length of stay was 7 days. Fifteen patients required a surgical
procedure after the endoscopic approach. Follow-up was 22
months in average (range: 1-73 months). Conclusion: The results
seens to justify the endoscopic treatments in patients over
79 years old but prospective randomized study matching surgery
versus endoscopic management is needed.
FP-113
LAPAROSCOPIC MANAGEMENT OF CHOLECYSTODUODENAL
FISTULAE
Erenchun C, Capellino P, Benavides F, Ramos R, Pierini I.
Background: Cholecystoduodenal fistulae is a very uncommon event
in the natural history of gallbladder stones. Its incidence increases
with age and it is present in 3-5% of patients with cholelithiasis. Objective:
To assess the outcomes of laparoscopic management of
cholecystoduodenal fistulae. Design: Retrospective study. Setting:
Private Hospital affiliated to Buenos Aires University. Patient and
methods: Thirteen patients underwent laparoscopic surgery with intraoperative
diagnosis of cholecystoduodenal fistulae from July 1998
and June 2003. Age, gender, procedure, conversion rate, morbility
and mortality was assessed. Results: Average age was 73.9 years
old, 10 patients were female. Conversion rate was 30% (4). Average
length of stay was 7.4 days. Morbility rate was 30% and there was no
mortality in this series. Conclusion: Videolaparoscopic approach to
cholecystoduodenal fistulae is feasible and safe. It still has a high
conversion rate.
FP-114
THROMBOPROPHYLAXIS WITH DALTEPARIN AFTER LAPARO-
SCOPIC CHOLECYSTECTOMY
edigraphic.com
32
Korolija D, Skegro M, Markicevic A, Vegar-Brozovic V, Predrijevac
D, Tadic S. University Surgical Clinic, Clinical Hospital Center Zagreb,
Zagreb, Croatia.
Background: The deep venous thrombosis reaches a high incidence
after abdominal surgery and occurs in 30-40% of the patients
operated. During the laparoscopic procedures, the intraabdominal
pressure is elevated due to the pneumoperitoneum. Thromboembolic
complications, including the portal vein thrombosis, have
been reported in the literature, previously. The application of the
low molecular weight heparins (LMWH) enables the deep venous
thrombosis prevention. Material and methods: In the period from
May 2001 to April 2002, a cohort of 212 patients was scheduled for
an elective laparoscopic cholecystectomy, in a Clinical (high-volume)
Hospital. In 30 patients with the identified risk factors, Dalteparin
sodium (2,500 IU or 5,000 IU) was administered subcutaneously.
During the first 30 postoperative days, a clinical follow-up was done
for the whole cohort. All complications, as well as thromboembolic
events, have been documented. Results: There were no major complications
observed. Five patients had intraabdominal (subhepatic)
hematoma and two of them were reoperated. The evacuation of the
hematoma and a drainage was done. There were no bile duct lesions.
None of the patients had the clinical signs of the deep venous
thrombosis or other thromboembolic complications. One unplanned
readmission to the hospital (patient reoperated for an intraabdominal
hematoma) was recorded. Conclusion: Dalteparin sodium
proved to be effective in preventing the thromboembolic complications
after laparoscopic cholecystectomy. Selective application,
according to the defined risk factors, gives very good clinical results
in everyday practice.
FP-115
LEARNING CURVE FOR LAPAROSCOPIC FUNDOPLICATION IN
TRAINING CENTER
Lopez CJA, Quinones MS, Guzman CF, Covarrubias MA, Lopez DJM.
IMSS Clinica 1 Tijuana, B.C.
Description: Objectives: To evaluate the learning curve of laparoscopic
fundoplication at IMSS training center Tijuana, B.C. Materials
and methods: From May 2002 to August 2003, 94 laparoscopic
fundoplication procedures were performed in which 46 of them
were female and 48 were male with an average age of 43.01. A
Nissen fundoplication was performed in 88 patients for GERD. Seven
patients had a partial fundoplication plus cardiomyotomy for achalasia.
Twelve surgeons with basic laparoscopic skills were trained
during this period. To evaluate the learning curve, the following parameters
were analyzed: Total OR time, complete knowledge of the
GE anatomy, short gastric vessels dissection and suture technique.
Results: The average OR time of the 94 procedures performed
was 141 minutes ranging from 35 to 310 minutes. Every surgeon
participated in at least 25 surgeries as first assistant and in at least
5 as the surgeon. Average hospital stay was 14 hours ranging from
6 to 72 hours. Cole-lap was performed in 9 patients, one laparoscopic
splenectomy and one patient had to be converted because
of bleeding. Discussion: One of the most important parameters to
evaluate the learning curve in this procedure is the surgical time
which should be similar or less than that of the open approach. In
this study, we were able to meet the requirements of the learning
curve after 25 procedures. The most difficult step of the procedure
to master was the short gastric vessels dissection.
FP-116
LONG-TERM COMPLICATIONS IN ANTIREFLUX PROCEDURE:
LAPAROSCOPIC TECHNIQUE
Manjarrez TA, Aguirre MD, González RR, Villegas CQ.
Purpose: This study was conducted to identify the post-surgical condition
of patients diagnosed with gastroesophageal reflux disease
who had received corrective laparoscopic antireflux surgery. A new
evaluation to identify the efficacy of the procedure was used. Signs
and long-term symptoms related to the surgical procedure were eval-

uated. Materials and methods: The study group included 195 patients
who had anti-reflux surgery by laparoscopy (Nissen, Toupet),
in San Jose Tec de Monterrey Hospital, from January 1993 to December
1999. The average follow-up was 3.1 years. The patients
personal data were reviewed and each were contacted to obtain
reported symptoms. Results: Of all the 195, 159 (81.5%) were found
asymptomatic. Of the reported symptoms, the most common was
gastritis, in 14 patients (7.1%), followed by flatulence and abdominal
distention in 8 cases; each (4.1%). Nausea was reported in 6
cases (3.0%). 5 patients had postprandial fullness, (2.5%) and 3
(1.5%) dysphagia. In 3% of the studied population, a repeat surgery
was conducted. There was a positive correlation of 3.75 times of
relapse postoperative gastritis, in the female study participants (RM
= 3.75; IC = (1.13, 12.3) (P = 0.05). Participants ranging in age 41-50
years were 10.1 times more probable to have continued reflux (RM
= 10.1; IC = (1.03, 99.06) (P = 0.05). Conclusions: Although the
laparoscopic surgery has surpassed the conventional technique,
there are continued complications of short and long-term; however,
with the innovative and modified techniques, a decrease in frequency,
of reflux has been achieved improving the morbidity of these
patients. This surgical procedure is sure to continue its evolution,
becoming even greater in its efficacy.
FP-117
LAPAROSCOPIC SURGERY FOR GASTRO-ESOPHAGEAL RE-
FLUX DISEASE IN CHILDREN. EARLY EXPERIENCE
Torices EE, Méndez VG, Domínguez CL, Velázquez GR, Tort MA,
Núñez GE, Olvera HH, Cuevas HF, Olvera AD, Mondragón SA.
Background. The use of laparoscopic antireflux surgery in the treatment
of refractory gastro-esophageal reflux disease in children is
growing quickly inside, it is well tolerated and controls symptoms
effectively, and less recovery time compared with open surgery.
Material and methods: We analyzed retrospectively charts of patients
with diagnosis of severe gastro-esophageal reflux disease
who were operated on laparoscopically from January 2002 to July
2003. We evaluated the following variables, sex, surgical procedure,
symptoms, added pathologies and complications. Results. In
all patients the diagnosis was made clinically, main symptom was
postprandial regurgitation. Four famales (30.8%) and 9 males
(69.2%) patients were studied, with median age 7.8 years old. Five
patients (38.5%) presented malnutrition and 2 patients (15.4%) recurrent
pneumonitis. Diagnosis was confirmed by endoscopy and
barium swallow. The average time of conservative treatment was 2
years, patients without appropriate response were selected for surgical
treatment. A total fundoplication without division of short gastric
vessels was carried out in all patients, 11 (84.6%) patients had
a good postoperative outcome remission of the symptomatology
and two patients (15.4%) presented recurrence that required laparoscopic
re-do surgery with a good outcome. Conclusions: Laparoscopic
approach offers better visualization with magnification of
the esophagus, with advantages of minimal invasive surgery, it reduces
hospital stay and morbidity. It is more affective than long
term medical treatment, with remission of respiratory complication
of GERD, as well as esophagitis.
FP-118
DECREASE AND DISAPPEARANCE OF BARRETT’S ESOPHA-
GUS IN GASTROESOPHAGEAL REFLUX WITH SURGICAL
TREATMENT
Lochnert RC, Glasinovic J, Santander R, Rios E, Finkelstein F, Rojas
H, Hamilton J, Lochnert RL. Clínica Alemana de Santiago, Chile.
Purpose: To evaluate prospectively the outcome of laparoscopic
fundoplication, with highly selective vagotomy in patients with Barret’s
esophagus, their disappearance, decrease or persistence. Material
and methods: Since March 1993, a personal prospective study
of 404 reflux patients were studied in accordance with a protocol,
and according to the results of their endoscopic biopsies they were
classified into two groups: those with Barret’s esophagus (152 patients)
and those without (252). Their symptomatology was as-
Abstract Book
edigraphic.com
33
sessed, and with, upper digestive endoscopy, X-ray of the esophagus,
stomach and duodenum, manometry and pH of 24 hours, the
factors affecting the formation of Barret’s esophagus were studied.
Both groups underwent procedures with laparoscopic highly selective
vagotomy with geometrically symmetrical Fundoplication and
closure of the pillars. They undergo yearly check-ups, and the variables
are analyzed. Results: The average age of the patients was
43.5 years; males were more frequent in the Barret group which
was statistically significant (p = 0.01) when comparing the two groups.
Symptomatology was constant for both groups, with high incidences
of pyrosis (88%) and regurgitation (75%). Previous history of reflux
was 9.1 years, with a standard deviation of 5.73 P = 0.84 (not
significant), endoscopy was grade 1 for 77 patients, grade II for 55
and grade III for 20 patients, according to the modified Savary classification,
P = 0.024. The 24-hour pH study showed a reflux index of
16.6 with a standard deviation of 13.924, significantly higher than
for the control group P = 0.0003. As for the DeMeester index, it behaved
in the same way: P = 0.0002, with a value of 60.015 and a
standard deviation of 44.485. The manometric study showed a pressure
of the lower esophageal sphincter of 8.072 with a standard
deviation of 13.976, which was not significant, P = 0.08. The total
length was 2.68 cm, with a standard deviation of 0.9 P = 0.64, but
the abdominal length of the sphincter was 0.641 with a standard
deviation of 0.505 P – 0.0029. Operating time for reflux was 120.7
minutes with a standard deviation of 35.3. Hiatus hernias were found
in 89.6% of the patients undergoing operations for reflux, with conversion
to open surgery in 1.5% of cases, with morbidity rate of 10.3%
and no mortality. In the annual check-up of the patients, we have
follow-up rate of 98.1% with 96.7% of healthy patients (Visick I); in
the third year, 95% of healthy patients, and 92.7% in the fifth year.
The monitoring of esophageal biopsies shows that 25.4% of the
Barret’s esophagus disappear within 36 months with a standard
deviation of 13.97. 30.3% decrease with a standard deviation of
9.86, and 44.3% remain unchanged with a standard deviation of
4.4. Conclusion: This is a prospective study of Barret’s esophagus.
We found that an average reflux index of 16.66 is statistically
significant P = 0.0003 in relation to the control group, as is the
DeMeester index of 60.01 P = 0.0002 as is the abdominal sphincter
length of 0.641 P = 0.002. We also found a rate of disappearance
of 25.4% and a 30.3% decrease in Barrett’s cases following 36
months of surgery.
FP-119
VIDEOLAPAROSCOPIC APPROACH OF DIFFUSE APPENDICU-
LAR PERITONITIS
Erenchun C, Minatti WR, Ramos RA, Pierini L, Capellino PH, Benavides
F.
Background: Videolaparoscopic approach to diffuse appendicular peritonitis
is considered by many authors as a contraindication. Good evidence
is still lacking. Objective: To analyze the outcome of videolaparoscopic
surgery in patients with diffuse peritonitis of appendicular
source. Design: Retrospective study. Setting: Private Hospital affiliated
to Buenos Aires University. Patients and method: Patients with intraoperative
diagnosis of diffuse appendicular peritonitis treated by
videolaparoscopic surgery were included from January 1995 to June
2002. Age, gender, conversion rate, length to stay, morbility and mortality
were assessed. Results: Eight hundred seventy five (875) videolaparoscopic
appendectomies were carried out in that period. Seventy two
(72) patients had diffuse peritonitis (8.2%). Average age was 53 + 24
years old (range 3-93). General morbility was 20.1% (15 patients). Three
patients needed to be reoperated. Bowel sound recovery time was 3.5
days (range 1-10). and patients start oral intake at 3 days in average.
Length of stay was 6.2 days (range 2-29). Mortality rate was 1.36% (1).
Conclusion: Videolaparoscopic approach to diffuse peritonitis of appendicular
source is a feasible and safe procedure.
V-120
LAPAROSCOPIC MANAGEMENT OF COMPLICATIONS AFTER
ACUTE APPENDICITIS
Velásquez CM, Vera PJ.

9 TH World Congress of Endoscopic Surgery
Description: We present a several cases of acute postoperative
appendicitis complications that were resulted by laparoscopy: Case
1: 54 male, with stercoraceus fistula and pericecal abscess with a
blocked dehiscence or the operative wound after a conventional
appendectomy through a Rocky Davis incision in a septic and compromised
patient. The management was done by laparoscopy with
drainage of the pericecal abscess, a tubular drain inserted and insulation
of stercoraceus fistula with the prompt recovery of the patient.
Case 2: 17 female, with appendicular flegmon treated medically,
after 30 days she became septic and the abdomen surgically
acute. By laparoscopy, a generalized peritonitis is found with a partial
digestion of the appendix. Case 3: 28 female, with good medical
treatment after four months a new episode of abdominal pain is
treated laparoscopically with soft and hard adhesions and acute
appendicitis that was managed successfully. Case 4: 32 male, with
HIV (+) to whom realized a conventional appendectomy without any
complications, a week later presents a progressive septic and hepatic
abscess chart. By laparoscopy, the hepatic abscess in posterior
segments is drained solving the complication presented. Case
5: 17 male, to whom realized an appendectomy by laparoscopic
surgery in appendicitis no complicated. It shows an evolution with
persistent pain and fever, getting better taking antibiotics by therapy
prolonged. At Seven months shows acute septic chart, CT presents
free liquid in cavity. By laparoscopy, there is an re-appendicitis
solved successfully.
FP-121
SUBFACIAL ENDOSCOPIC PERFORATING VEIN SURGERY: 4
YEARS OF EXPERIENCE IN GUILLERMO ALMENARA IRIGOYEN
HOSPITAL
Castro D, Castro H, Yeper R. Guillermo Almenara Irigoyen Hospital
Lima Perú.
Purpose: To describe the clinic features and surgical management
of the patients submitted to Subfacial Endoscopic Perforating
Vein Surgery. Methods: This study is a Case Related Series.
The population involve all the patients submitted to Subfacial Endoscopic
Perforating Vein Surgery between October 1999-September
2003. The exclusion criteria were patients without source
data not available or incomplete. The statical analysis used was
rate, media, percentage and standard derivation. Results: It was
enrolled/109 patients, 4 patients were excluded because source
data incomplete the age average was 50.36 years old. The main
interval was between 40 and 79 years old. The total of patients
with ulcer before the surgery were 71, and the total of extremities
with ulcer operated were 90. Nine patients with two ulcers and two
patients with three ulcers. The sexual distribution was 53%, female
and 47% male. The 44% of patients had Venous Cronic Insufficiency
Grade VI. The interval of time of disease was 1-5 years in 46.9%,
11-20 years in 19-7%. 72.73% of the patients didn’t have prior surgery,
10.81% had Safenectomy plus Collateral Ligation. The total
contraindications to this kind of surgery were Arteriosclerosis, Infected
Ulcer, Morbidity Obesity and High Risk Patients to Surgery.
The surgery time was 128 minutes, the average of perforants vein
were 5.28 per patient and the number of legs operated were 119.
The 80% of patients didn’t have complication after surgery and almost
10% had cellulitis. Only 5.13% had persistency of the ulcer
after the surgery and the average of ulcer closing was 8.2 weeks.
Only 5.36% had ulcer recidive after the surgery. Conclusions: Ulcer
morbidity almost disappeared. The Endoscopic Surgery identify
better the perforating veins. The ligation of perforator veins is safer
with this procedure. The healing of the ulcer is faster and better than
the open surgery. The symptoms of CVI grade IV get better with this
procedure: Prevent the neuromuscular damage.
FP-122
PALLIATIVE LAPAROSCOPIC TREATMENT FOR PATIENTS WITH
AMPULLARY TUMORS
Mondragón SA, Alvear NM, Alcántara TVM, Mondragón SR. Department
of Endoscopic Surgery. Centro Medico ISSEMYM. Edo de
México, México.
edigraphic.com
34
Background: Laparoscopy has proved its usefulness in patients with
non resecable pancreatic cancer. It can be used only as staging
laparoscopy or also for palliative treatment, decreasing the number
of unnecessary laparotomies, hospitalization time and morbi-mortality
rate. Patients and methods: From May 2002 thru August 2003, we
studied prospectively the utility of palliative laparoscopic treatment
in patients with periampullary non-resectable tumors. All patients
with periampullary tumors in ISSEMYM Medical Center were evaluated
preoperatively with CA 19-9 antigen, CEA and computed tomography
to determine resecability. All patients underwent an staging
laparoscopy and patients with tumors determined irresectable
with gastric or biliary obstruction, were selected for palliative laparoscopic
treatment. Results: Five patients were selected for this
study. All patients were male, age from 39-66 years (m 56 years), 4
patients with pancreatic head cancer and one patient with gastric
cancer recurrent to the pancreatic head. Three patients were operated
on with gastric and biliary by-pass (cholecysto-jejuno anastomosis
and gastro-jejuno anastomosis); and two only biliary by-pass.
The median operative time was 190 minutes, median blood loss
100 mL; the convertion rate was 0% and the median hospitalization
time was 5 days. In this series there were no major or complications.
Conclusions: Even though this is a small series our results
demonstrate safeness and feasibility for laparoscopic palliative treatment
in pancreatic cancer. Controlled prospective trials are necessary
to determine advantages against conventional surgery.
V-123
LAPAROSCOPIC ROUX-EN-Y CYSTOJEJUNOSTOMY FOR PAN-
CREATIC PSEUDOCYST
Tan CN, Chan KKL, Ha JPY, Li MKW.
Internal drainage is the treatment of choice for pancreatic pseudocyst
when it is larger than 6 cm and persists more than 6 weeks. Cystojejunostomy
in Roux-en-Y fashion would be the choice if the main bulk
of cyst is located mainly in the infracolic compartment. We here reported
a case of symptomatic pseudocyst treated successfully with
laparoscopic Roux-en-Y cystojejunostomy. Our patient was a
38-year-old lady who presented with left upper quadrant pain. Physical
examination revealed a mass below the left costal margin and the
pancreatic pseudocyst was confirmed by both ultrasound and computed
tomography. The cyst measured 17 cm and located at body
and tail of pancreas. The laparoscopic drainage was performed using
a 4 port approach and lasted only 90 minutes. The cyst was drained
and sutured to the Roux loop of jejunum using endostapler and the
jejuno-jejunostomy was again performed using endostapler. The patient
recovered uneventfully and was discharge day 3 after the operation.
Upon a follow up of 1 year, there was no complication found
and patient remained symptom free.
V-124
LAPAROSCOPIC SEGMENTAL PANCREATIC RESECTION
Baca I. Klinik fuer Allgemein-und Unfallchirurgie, Krankenhaus Bremen
Ost, Bremen.
Beside the location, the complex anatomic relationship and the necessary
advanced laparoscopic skills in selected cases laparoscopic
pancreas surgery increase. We show a video in cases of cystic
adenoma in the area of the corpus, who was treated with a technique
of complete laparoscopic corpus resection with preserving
head and tail of the pancreas as well as the spleen. Patient was
placed in lithotomy position. Four trocars were placed. After opening
the bursa the pancreas was observed with a 6 x 6 x 6 cm
large, well borderd cystic tumor in the corpus. Tail and head of the
pancreas were free of tumor and seems inconspicuous. After exposition
of the v. porte and v. lienalis the health tissue in the area
of the head of pancreas was divided with the linear stapler. Preparation
was continued in direction of the pancreatic tail with preserving
the v. lienalis. After reaching the healthy part of pancreas
in the tail region, the tumor covered segment was resected. The

esected pancreas segment was put in an endobag until solvage
over a slightly wided trocar incision above the symphysis. The tail
segment in situ was anastomized with the first jejunum loop after
Treitz ligament end-to-site. There was no postoperative complication
and postoperative course was uneventful. The patient return
to normal activity within 10 days after operation. Laparoscopic operation
in case of benign tumors of distal pancreas are possible
with well surgical standard, preserving the health part of pancreas
tissue and laparoscopic anastomosis with all benefits of minimal
surgical access for the patients
V-125
LAPAROSCOPIC ASSISTED PANCREATICODUODENECTOMY
Puntambekar SP, Gurjar A, Sathe R, Kulkarni J.
Introduction: Pancreaticodudenectomy is a major surgical procedure
performed in specialized centers in the world. This is due to
the high morbidity and mortality associated with this procedure. The
technical expertise and the experience of the surgeon is of paramount
importance in deciding the ultimate outcome. A big incision is
needed to visualize the detailed anatomy and this certainly adds to
the morbidity. Any additional technique which can reduce the surgical
incision without compromising the oncological principles as well
as the safety of the patient is desirable. Laparoscopy has an advantage
of magnification and precision which leads to a better anatomical
delineation. In addition, it can reduce the morbidity by reducing
the size of incision. There are very few reports of laparoscopic
pancreatico-duodenectomy as this requires patience. Surgical experience
and laparoscopic expertise. Methods: Since 1993, we have
performed 85 pancreatico-duodenectomies with 20% morbidity and
7% mortality. Recently, we have performed 2 pancreatico- duodenectomies
laparoscopically. Both were male patients, with periampullary
cancers. Five ports, three 10 mm and two 5 mm were used. The
total time taken was six hours, and blood loss was 500 mL. After
complete removal of the specimen laparoscopically, the anastomosis
and intestinal continuity was established through a small incision.
Both the patients have done well following these procedures.
Observation: We would like to present our experience and show
the technical feasibility of performing this complicated surgery laparoscopically.
V-126
VIDEOLAPAROSCOPIC HAND ASSISTED ENUCLEATION OF
PANCREATIC INSULINOMA
Statti M, Pierini L, Benavides F, Premoli G, Mendiburu A.
Background: Videolaparoscopy is a therapeutic alternative in endocrines
tumours of pancreas. There are several reports that support
the advantages of videolaparoscopic approach for its enucleation.
Objective: To show a case of hand assisted enucleation of pancreatic
insulinoma. Setting: Private Hospital affiliated to Buenos Aires
University. Design: Video. Patient: Male of 78 years old complaining
of sweating, blur vision, nervousness and hunger. Laboratoy: hypoglycemia
with hyperinsulinemia. I/G ratio = 0.44. MRI finding a
pancreatic nodule of one centimeter at posterior face of pancreatic
body. Surgical technique: Three ports of 10 mm: Upper umbilical,
left upper quadrant and left paraumbilical. Laparoscopic releasing of
splenic flexure of colon and visual approach to pancreas. Left hand
introduction throught a 5 centimeter incision located at right flank.
Digital enucleation with grasping helping. Anatomo-pathology: Insulinoma
without vascular or capsular infiltration. Conclusion:
Videolaparoscopic hand-assisted enucleation of pancreatic insulinoma
is feasible and safe.
V-127
LAPAROSCOPIC MANAGEMENT OF A LARGE PANCRETIC
PSEUDOCYST BY CYSTO-JEJUNOSTOMY
Abstract Book
edigraphic.com
35
España-Gómez MN, Argote-Greene LM, Pantoja JP, Herrera MF.
Department of Surgery. Instituto Nacional de Ciencias Médicas y
Nutrición Salvador Zubirán. Mexico City. MEXICO.
Pancreatic pseudocyst occur as a consequence of acute or chronic
pancreatitis. They consist of fluid collections surrounded by fibrous
tissue with lack of epithelial lining. Laparoscopic drainage of pancreatic
pseudocyst has been used in selected cases. We have
advocated to tailor the type of drainage according to the position
and site of the pseudocyst. This video shows a laparoscopic
Roux-en-Y cystojejunostomy performed in a 70 year old patient
with a history of biliar pancreatitis. Six month after the acute attack
of pancreatitis a 18 x 11 x 14 cm pancreatic pseudocyst was
diagnosed by CT scan. A transmesocolic cysto-jejunostomy was
performed using an standard technique. The use of intraoperative
ultrasound to asses the characteristics of the pseudocyst and to
roule out adjacent collections is enphatized. Postoperative recovery
was uneventful. He was discharged asymptomatic on the 3rd
postoperative day.
FP-128
LATERAL INTRAPERITONEAL LAPAROSCOPIC ADRENALECTO-
MY. IS IT SAFE?
Pantoja JP, Cordón CR, Gamino SWR, Rull-Rodrigo JA, Herrera MF.
Departments ot Surgery and Internal Medicine, Instituto Nacional de
Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, MEXICO.
Introduction: Since the first laparoscopic adrenalectomy performed
in 1992 by Gagner and colleagues, the minimally invasive
approach has become the standard of care for most adrenal tumors
and hyperplasia. Several techniques have been proposed.
The purpose of this study is to evaluate our results using the laparoscopic
transperitoneal flank approach. Patients and methods:
In a 7-year period, a total of 125 adrenalectomies were performed
in 90 patients. We analyze demographic data, operative characteristics,
complications and long term results. Indications for
adrenalectomy were Cushing disease in 32 patients (bilateral
adrenalectomy), pheochromocytoma in 18 (2 bilateral due to NEM
II), cortisol producing adenoma in 13, Conn syndrome in 13 (1 bilatelaral
hyperplasia), adrenal incidentaloma 6, virilizing tumor 5,
adrenal cyst 2 and lymphoma 1. Results: Mean operative time was
192 min ± 66 (60-340) for unilateral adrenalectomy, and 290 min
± 87 (180-480) for the bilateral procedures. Complete resection of
the gland and tumor was achieved in al patients. The were 3 major
complications (hypoglycemic encephalopathy, pneumothorax, and
postoperative bleeding that required surgical revision). There was
a 2% conversion rate (3 patients). There were 2 deaths in the 30-day
postoperative period, due to complications not related to the procedure
(Upper gastrointestinal tract bleeding, and bronchoaspiration
in a patient with a concomitant lung resection. There has not
been recurrence of the disease due to remnant unresected tissue
in any patient. Conclusions: Minimally invasive adrenalectomy
using the lateral intraperitoneal approach is safe and effective for
the management of benign adrenal tumors and hyperplasia.
V-129
LAPAROSCOPIC RESECTION OF A PEOCHROMOCYTOMA IN A
PREGNANT WOMAN
España-Gómez MN, Lozano-Salazar RR, Pantoja JP, Herrera MF.
Department of Surgery. Instituto Nacional de Ciencias Médicas y
Nutrición Salvador Zubirán. Mexico City. MEXICO.
Unrecognized or untreated pheochromocytomas during pregnancy
have serious risks of maternal-fetal mortality. These are markedly
improved with early detection, pharmacological adrenergic blockade
and elective removal of the adrenal tumor. The ideal time to remove
a pheochromocytoma diagnosed in pregnancy is at the beginning of
the second trimester. Spontaneous abortion is less likely to occur

9 TH World Congress of Endoscopic Surgery
since the gravid uterus is not yet large enough to interfere with the
surgical field. This video shows an adrenalectomy performed in a 28
year old woman with a history of severe toxemia during the first pregnancy.
During the 12 week of gestation of the second pregnancy she
presented arterial hypertension (160-110) without symptoms. Renal
ultrasonography revealed a left adrenal mass. The 24 hr urinary catecholamines
were elevated (7024 µg) and plasma catecholamines
were also elevated (9238 pg/mL). A magnetic resonance imaging
was performed and showed a left adrenal tumor (56 x 44 x 63 mm).
The patient was prepared with α-blockers for two weeks and
β-blockers for one week. Once satisfactory blockage was achieved,
laparoscopic adrenalectomy was performed using the lateral intraperitoneal
approach. Postoperative recovery was uneventful. An obstetric
ultrasound performed immediately after surgery confirmed good
placental attachment and no signs of fetal distress. Patient was discharged
asymptomatic and with normal arterial blood pressure on
the 3rd postoperative day.
FP-130
LAPAROSCOPIC HAND ASSISTED LEFT ADRENALECTOMY IN
PHEOCHROMOCYTOMA
Villalobos-Alva A, Carvajal-García R, Fuentes-Flores F,
Legoff-Engwall N. Department of Surgery. Hospital Valentín Gómez
Farías, ISSSTE, Guadalajara, Jalisco, México.
Purpose: Laparoscopic adrenalectomy is actually the standard
technique to remove benign adrenal tumors. There has been described
retroperitoneal and transperitoneal techniques. In large
series, its application has been limited to lesions lees than 6 cm
size. Hand assisted technique facilitates dissection and mobilization
of larger tumors, enables tactile sensation and decreases
learning curve. Methods: It’s presented a famale patient 40 years
old, with a large, unique left adrenal mass, adrenergic manifestations
and hypertension. The diagnostic of pheochromocitoma is
made by clinical, MRI and urine methanephrines. A laparoscopic
hand assisted adrenalectomy was performed. Through a hand
assisted device and two 10 mm trocars, colon and spleen were
mobilized medially, Gerota’s fascia opened and adrenal vein identified
and divided. Adhesions of tumor are divided from aorta, pancreas,
renal vein and retroperitoneal space. Results: A hypertensive
period was experienced by the patient during operation and
successfully managed with esmolol and sodium nitroprusiate. The
patient is referred 24 h to ICU and 72 h postop is discharged.
Pathologist reports a benign pheochromocytoma. Conclusions:
Laparoscopic hand assisted adrenalectomy is a safe and effective
approach. It is technically fusible in adrenal masses larger
than 6 cm. Enables less manipulation of adrenal vein.
V-131
LAPAROSCOPIC RIGHT AND LEFT ADRENALECTOMIES: TECH-
NIQUE WITH LATERAL POSITION
Amicucci G, Schietroma M, Franchi L, Mazzotta C. Departments of
Surgical Science, University of L’ Aquila, Italy.
Purpose: Laparoscopic approach for adrenalectomy using a lateral
position was firstly described by Gagner. This study has been
performed to evaluate the procedure in comparison with the conventional
surgery. Methods: 23 laparoscopic adrenalectomies (12
for the right glande, 11 for the left) were performed between 1995
and 2003 in 13 females and 10 males ranging in age from 32 to 73
years. Main indications were Cushing’s syndrome, Conn’s syndrome,
small primary and metastatic tumors. A full lateral decubitus
on the left side was used for right adrenalectomy whereas a
right decubitus was used for the left adrenalectomy. Usually 3 or
4 trocars were employed right adrenalectomy: section of peritoneum
under the liver. The adrenal gland was easily identified posteriorly
and inferiorly to the liver. Section of the main adrenal vein
and research of an accessory adrenal vein. Dissection of peri-
edigraphic.com
36
glandular tisssue. The gland was inserted into an extraction beg.
Left adrenalectomy: dissection of spleno-phrenic, phreno colic and
spleno-colic ligaments to allow, a complete mobilization of the
spleen. Retroperitoneal dissection for the exposure of the renal
vein. Division of the lower adrenal vein dissection of the periglandular
tissue with harmonic scalpel (Ethicon Endosurgery), used
also to divide the upper adrenal rein and artery. The gland was
inserted into an extraction bagand removed. Aspirative drainage
was employed in every case and removed in the second operative
day. Results: The median surgical time was 110 minutes. No
mortality occurred postoperative morbidity consisted of a left pleural
effusion in four patients. The median hospital stay was 4 days.
Conclusions: Laparoscopic adrenalectomy in a lateral position is
a safe procedure and combines the advantages to boyh anterior
and posterior conventional approach.
FP-132
SIMPLIFIED GASTRIC BYPASS – 522 INITIAL CASES
Cardoso RA, Galvão NM, Galvão M, Carlo A. Gastro Obeso Center–
São Paulo-Brazil.
Background: The gastric bypass is considered the golden standard
in the surgical treatment of morbid obesity. Although this procedure
still be doing by laparotomy in most of the cases, laparoscopic
approach is feasible, safe with good results and is grow in
number. It is considered one of the most complex procedures in
laparoscopy, requiring a large series to achieve the learning curve.
So, any maneuver, technique or approaches who can improve it´s
complexity are welcome. AIM: Evaluate the technique and initial
results of Simplified Gastric Bypass (SGB) approach. Casuistic:
Between December of 2001 and July of 2003, 522 SGB patients
records were analyzed in a retrospective manner, 313 were female
(59.9%), age range from 14 a 64y (M = 36,5y), weight range from
90 a 202 kg (M = 132 kg) and BMI were between 37 a 66 kg/m 2 (M
= 44 kg/m 2 ). The Simplified technique (to be presented) is based in
doing all of the anastomoses in the supra-mesocolic “floor” with the
trocars in similar position of lap Nissen procedure. Results: There
was no conversion to laparotomy at this series. BMI came from a
mean of 44 to 28.4 kg/m 2 (63.3% EBMIL –Excess BMI loss). Operative
time stays between 39 to 154 min (M = 75 min), Hospital stay
within 1.5 to 6d (M = 3d). Complications occurred in 2.87% of ulcers,
2.5% of gastrojejunostomy strictures, 1.4% of leakage, 0.19%
of digestive bleeding, 0.57% bowel obstruction. Re-operation was
done in 1.91% and there were 0.95% of deaths (3p with pulmonary
embolism. e 2p with sepsis due to gastrojejunostomy leakage).
Conclusion: The Simplified Gastric Bypass proved to be at it’s initial
results; safe, less time consuming and efficient in reducing patients
BMI with low complication and death rates.
FP-133
UMBILICAL DEFECTS BEFORE AND AFTER LAPAROSCOPIC
CHOLECYSTECTOMY: DECREASING THE INCIDENCE OF
POST-LAPAROSCOPIC INCISIONAL HERNIA
Hamouda AH, Ilham M, Khan M, Mahmud S, Nassar AHM.
Aims: The reported incidence of post-cholecystectomy incisional
herniation is 0.8-3%. Wound extension seems to be an important
etiological factor. This study aims to evaluate the effect of adopting
a standard technique for access, gallbladder extraction and
closure on the incidence of post-operative hernia after laparoscopic
cholecystectomy (LC). Patients and methods: 900 LC’s were performed
in one unit over 7 years. Pre-existing defects were documented.
The 10 mm umbilical port was established by direct access,
through a fascial incision smaller than 10 mm, entering the
peritoneal cavity with blunt forceps before wedging-in the cannula.
Gallbladder extraction was done only after evacuating bile and
stones allowing removal without wound extension. Umbilical port
closure was achieved using an absorbable suture between two

lunt hooks tenting the fascia under vision and umbilical hernias
larger than 2 cm were repaired using nonabsorbable sutures. Results:
57 pre-existing umbilical defects (6.3%) were used for access
and then repaired after LC. Postoperative incisional hernia
occurred in 3/900 patients (0.33%) with an average age 67 years.
None of the patients were diabetic, one patient had a pre-existing
umbilical defect and no wound infections were recorded. Incisional
herniation was detected 4, 8 and 9 months postoperatively and
necessitated repair in only 1 case, 11 months after operation. The
hernia was umbilical in 1 patient, epigastric in 1 and combined in
the third. None of the patients had wound extension. Conclusion:
Pre-existing umbilical defects must be documented and repaired.
The incidence of postcholecystectomy umbilical incisional herniation
can be minimized by avoiding the classical Hasson technique,
careful gallbladder extraction, avoiding wound extension and using
a sound fascial
FP-134
LAPAROSCOPIC VENTRAL AND INCISIONAL HERNIA REPAIR:
11-YEAR EXPERIENCE
Manjarrez TA, Treviño J, Franklin M, Glass JL, González JJ.
Purpose: Incisional hernias develop in 2% to 13% of laparotomy
incisions, necessitating approximately 90,000 ventral hernia repairs
per year. Although a common general surgical problem, a “best”
method for repair has yet to be identified as evidenced by documented
recurrence rates of 25% to 52% with primary open repair.
The aim of this study was to evaluate the efficacy and safety of
laparoscopic ventral and incisional herniorrhaphy. Materials and
methods: From February 1991 through November 2002, a total of
382 patients were treated by laparoscopic technique for primary
and recurrent umbilical hernias, ventral incisional hernias, and Spigelian
hernias. The technique was essentially the same for each procedure
and involved lysis of adhesions, reduction of hernia contents,
closure of the defect, and 3-5 cm circumferential mesh coverage
of all hernias. Results: Of the 382 patients in our study group,
there were 212 females and 172 males with a mean age of 58.3
years (range 27-100 years). Ninety-six percent of the hernia repairs
were completed laparoscopically. Mean operating time was
68 minutes (range 14-405 minutes), and estimated average blood
loss was 25 mL (range 10 to 200 mL). The mean postoperative
hospital stay was 2.9 days and ranged from same-day discharge to
36 days. The overall postoperative complication rate was 10.1%.
There have been 11 recurrences (2.9%) during a mean follow-up
time of 47.1 months (range 1-141 months). Conclusion: Laparoscopic
ventral and incisional hernia repair, based on the
Rives-Stoppa technique, is a safe, feasible, and effective alternative
to open techniques. More long-term follow-up is still required to
further evaluate the true effectiveness of this operation.
FP-135
ENDOSCOPIC TOTALLY EXTRAPERITONEAL INGUINAL HERNIA
REPAIR-A SERIES OF 200 REPAIRS
Cheah WK, So JBY, Lomanto D. Minimally Invasive Surgical Centre
(MISC), Department of Surgery, National
University Hospital and NUS, Singapore.
Description: Aim: The addition of laparoscopic repairs only adds
to the complexity of choosing the best hernia repair among the
numerous types that have been described, but as history shows
the best repair is the one that the surgeon has the greatest experience
in and thus the lowest recurrence and complication rates.
Laparoscopic hernia surgery has maintained its role because of
the benefits to patients that are evident when compared to open
repairs, as reported in many published randomized controlled trials.
To review the experience of endoscopic totally extraperitoneal
hernia repair (TEP) in a major teaching hospital. Methods: A
review was undertaken of 160 consecutive patients who under-
Abstract Book
edigraphic.com
37
went TEP for inguinal hernia between 1998 and 2003 at the National
University Hospital, Singapore. Results: The 160 patients
had 200 hernia repairs (120 unilateral and 40 bilateral hernias).
The mean age was 51 years and 95% were men. The overall mean
operative duration was 70 minutes; bilateral repairs took 27% longer
than unilateral repairs. Four patients had conversion to open
surgery, and 10 patients developed minor complications (groin
seroma). Seven patients (3%) developed hernia recurrence, but
there was no recurrence detected in the last 52% of cases. The
recurrence rate was higher when the mesh was not anchored (5 of
41 patients; 12%) than when the mesh was anchored (2 of 119
cases; 1.6%). The mean inpatient hospital stay was 1.4 days, and
of the last 30 cases, 70% were performed as outpatient. Conclusion:
Endoscopic TEP is a viable alternative to open hernia repair.
To achieve good results, adequate cases should be performed
to overcome the learning curve, and that the mesh should be anchored
to the inguinal floor.
FP-136
LEARNING CURVE IN INGUINAL HERNIA REPAIR BY LAPARO-
SCOPIC APPROACH
López DJM, López CJA, Guzmán CF, Covarrubias M. Hospital Regional
No. 1 IMSS Tijuana, B.C.
Objectives: To analyze the results of the learning curve in inguinal
hernia repair by laparoscopic approach. Materials and methods:
From February 1995 to August 2002, 1,050 inguinal hernia repairs
were performed in 1,000 patients in the IMSS training center Tijuana,
Mex. General anesthesia was used in all patients and the decision
to perform TAPP (trans-abdominal pre-peritoneal) or TEP (totally
extra peritoneal) technique was randomly taken. Thirty eight
surgeons with basic laparoscopic skills were trained and their evaluation
was based on the following standards: 1. The number of
procedures needed to obtain complete knowledge of the posterior
inguinal region anatomy. 2. OR time. 3. Complications. Results:
Laparoscopic inguinal hernia repair was performed in a total of
1,000 patients, in which 50 of them were bilateral. 78% were male,
22% were female. Their ages ranging from 17 to 84 years with an
average of 42 years. The most frequent type was indirect hernia
in 760 patients (76%), direct in 220 patients (22%) and femoral in
20 patients (2%). TAPP procedure was performed in 580 patients
(58%) and TEP in 420 patients (42%) with a morbidity of 8.5% (85
patients). Fifty seven patients presented seroma (5.7%), 7 had
wound infection (0.7%), 3 patients had nerve lesion (0.3%), 2 patients
had to be reoperated because of bleeding (0.2%), 1 patient
presented mesh migration (0.1%). The recurrence rate was 1.5%
(15 patients). Thirty procedures were needed to obtain adequate
knowledge of the preperitoneal inguinal region and stabilization of
OR time, which varied from 15 to 180 min with an average of 70
min. Some of these procedures had to be completed by one of the
proctors because of technical difficulties. Discussion: The learning
curve of the laparoscopic inguinal hernia repair takes a large
number of procedures (at least 30) to be mastered because of the
lack of knowledge of the region’s anatomy and its technical difficulties.
It is considered an advanced laparoscopic procedure but
once it is mastered, the results should be similar or even superior
to those of the open approach.
FP-137
TOTAL EXTRAPERITONEAL LAPAROSCOPIC HERNIORRHAPHY
USING KUGEL PATCH
Ohira M, Urushihara T, Sumimoto K.
Description: Introduction: Kugel method is recently used for preperitoneal
inguinal hernia repair because of tension free and sutureless
fasion through a very small incision. Although it had very
good result, it was difficult to confirm whether the mesh was adequate
position because of small working space. So we had a good

9 TH World Congress of Endoscopic Surgery
working space with combination of abdominal wall lifting and lowpressure
pneumopreperitoneum and performed total extraperitoneal
laparoscopic herniorrhaphy using Kugel patch. Patients and
methods: Between January 2002 and October 2003, total extraperitoneal
laparoscopic herniorrhaphy using Kugel patch was carried
out on 18 patients (3 patients had bilateral hernias) with a
median age of 68.6 (47 to 89) years. Surgical procedure as follow:
Under spinal anesthesia, the patient is placed in the supine position.
A 12 mm infraumbilical skin incision is made and the fascia is
incised. Extraperitoneal dissection is accomplished using a balloon
device. A 12 mm trocar is inserted into the extraperitoneal
cavity from this incision. Abdominal wall lifting using Kirschner’s
wires can provide a wide operative field of vision with pneumopreperitoneum.
Carbon dioxide is introduced into the extraperitoneal
cavity until reading a pressure of 4 mmHg. Subsequently, two 5
mm trocars are inserted into the extraperitoneal cavity. The vas
deferens and genital vessels are teased away from the posterior
aspect of the sac by sharp dissection. The sac is ligated and
transected, and the distal part of sac is left undisturbed. A Kugel
patch is inserted from the 12 mm trocar into the extraperitoneal
cavity. The mesh complete covers to the underlying Cooper’s ligament,
the iliopubic tract, transverses abdominus and lateral border
of the rectus and fixed with the Protack. Finally we confirm
whether the mesh is adequate with the laparoscope. Results: The
median operative time was 68.7 (44 to 106) minutes. There was
no case of postoperative complications; hematoma, seroma and
transient neuralgia. The median time, it took the patients to return
to their normal activities, was 7.8 days. There was no case of
recurrence during follow up (1 to 22 months). Conclusion: Total
extraperitoneal laparoscopic herniorrhaphy using Kugel patch was
safe and effective procedure for inguinal herniorrhaphy.
FP-138
LAPAROSCOPIC CORRECTION OF DIAPHRAGMATIC TRAUMAT-
IC HERNIAS. REPORT OF 13 CASES
Vergnaud JP, Lopera C, Vásquez J. Department of General Surgery.
Instituto de Ciencias de la Salud, CES. Medellín, Colombia.
Purpose: Describe the laparoscopic management of 13 patients with
left diaphragmatic traumatic hernias. Methods: Descriptive study of
non consecutive patients. The procedures were performed in different
clinics and hospitals of the city. Results: We included 13 patients
who required diagnosis or repair of left diaphragmatic injuries.
One patient required conversion to an open procedure and the
remaining 12, the correction were performed laparoscopically. In 9
patients, the mechanism of trauma was penetrating (4 patients stab
wounds and 5 patients shot gun wounds) and blunt trauma in the
remaining 4. In 10 patients the repair was done some hours after
the trauma and 3 patients presented late onset diaphragmatic hernias.
Two of these 3 patients required a mesh to cover the defect. In
acute presentation hernias, the repair did not required mesh and
just required primary repair. One patient presented a severe trauma
index that required management at the Intensive Care Unit. In these
particular patient, postoperative complications ocurred and the hospital
stay was 33 days, both related to the extent of the trauma. The
remaining patients no presented any complications and the average
hospital stay in this group was 3 days. Conclusions: Laparoscopy
is appropriate for the management of left diaphragmatic traumatic
hernias in hemodinamically stable patients who did not require
laparotomy or thoracotomy for other reasons.
FP-139
SILICONE COVERED LOW WEIGHT POLYPROPYLENE MESH
(LOPROSI) FOR LAPAROSCOPIC REPAIR OF VENTRAL HERNI-
AS: ANIMAL STUDY AND INITIAL CLINICAL EXPERIENCES
Weber G, Baracs J, Saájadi S, Vereczkei A, Gal I, Horváth OP. Department
of Surgery, Medical Faculty, University of Pécs and Department
of Surgery, Bugat, Pál Hospital, Gyöngyös, Hungary.
edigraphic.com
this unique problem.
38
Purpose: The effect of silicone-membrane in prevention of adhesions
to intraabdominally placed polypropylene meshes have been evaluated.
Methods: In 24 white rabbits two full-thickness 3x4 cm symmetric
contralateral defects were made in the abdominal wall. In the first
12 rabbits the left side defect was , covered by a polypropylene (PP)
mesh covered with a silicone membrane in a way that the covered
surface of the mesh was put in contact with the visceral peritoneum.
As a control, the right side defect was covered by a PP mesh alone.
In the next 12 rabbits the biological response of silicone membrane
protected material-reduced mesh was evaluated: in all rabbits, on the
left side silicone-covered low weight PP mesh, on the right side uncovered
low weight PP mesh was implanted. The animals from each
group were studied at 7th, 14th, 30th, 60th, 90th and 120th postoperative
day, respectively, to determine the degree 6 of adhesion formation
and its macro-and microscopic appearance. Based on the
promising animal studies and having ethical committee permission
we have started a multicentric study to investigate the clinical relevance
of LOPROSI. In clinical evaluation a prospective study was
performed including 12 patients (9 women and 3 men) with a mean
age of 54 years (range 39-69 y), Results: In animal settings the
silicone-membrane decreased adhesions significantly. In the clinical
study was no mortality were no wound or mesh infections. In one
case prolonged ileus was noted. Scans of six patients showed small
fluid collections within the abdominal wall between the hernia sac
and the mesh. These collections resolved within the first 30 days
without aspiration. Clinically evident seromas were found in another
four cases and multiple aspirations were needed for 2 and 4 months.
During a mean follow-up period of 5 months we found no infections,
rejections, fistulas, or recurrences. Conclusions: Although only a
small number of patients were studied, low weight polypropylene mesh
protected with silicone-membrane appears to be a promising combination
for intraperitoneal hernia repair.
V-140
LAPAROSCOPIC MANAGEMENT OF INCARCERATED CRURAL
HERNIA
Velasquez CM.
Description: We present many cases of complexity progressive of
incarcerated crural hernia and its laparoscopic approach or management.
Case 1: Left crural hernia with ileal asa incarcerated that recovers
its motility and color. So, the hernioplasty is completed by TEP.
Case 2: Right crural hernia with antimesenteric cecal incarcerated
(Ritcher’s hernia) edge that dont recover. TEP hernioplasty is realized.
Case 3: Right crural hernia with asa ileal strangled that dont
retrieve totally. Hernia ring closed for laparoscopy, conversion and
intestinal resection are realized, however the hernioplasty is postponed
to the second intervention.
V-141
LAPAROSCOPIC REPAIR OF SPIGELIAN HERNIA
Saber AA, Palermo D, Lloyd D, Mubarak O.
Introduction: Spigelian hernias are a rare entity. Laparoscopic approach
to such a unique hernia can be both diagnostic and therapeutic.
A recent MEDLINE search identified only thirteen reported
cases of laparoscopic repair of spigelian hernias. Technique: The
author presents a simple technique for laparoscopic mesh repair
of spigelian hernias. This technique allows simple mesh placement
and orientation to overlap the hernia defect. Conclusion: Laparoscopic
repair of a Spigelian hernia is a feasible option to address
V-142
LAPAROSCOPIC CORRECTION OF A LEFT DIAPHRAGMATIC
HERNIA CAUSED BY SHOT GUN TRAUMA
Vergnaud JP, Lopera C. Clinica CES, Medellín, Colombia.

33 year-old male patient who suffered a left thoracoabdominal shut
gun trauma. The bullet entered the thorax in the fifth intercostal space
at midaxilary line and was lodged at the twelfth thoracic vertebral
body. At the emergency room the patient was hemodinamically stable,
without peritoneal signs or respiratory distress. The laparoscopy
showed a 2 cm posterior diaphragmatic defect, two fundic injuries
and a non bleeding grade I spleen injury. The diaphragm was corrected
whit non absorbable suture and the gastric fundus was sutured
with an absorbable material. The patient did not present any
complications, the thoracic tube was withdrawn at the third day and
the hospital stay was four days.
V-143
HYPOVOLEMIC SHOCK SECONDARY TO A RUPTURE OF EC-
TOPIC SALPHINX PREGNANCY. LAPAROSCOPIC APPROACH
Martinez HF, Lozada LJD, Vargas VJL, Contreras AA, Abúndez PA,
Carreto AF. Santa Monica Hospital, Cuernavaca, Morelos, México.
Purpose: The objective of this video is to present us the surgical
technique. Material and methods: We present us the clinical case
of a 22 years old female patient, nulipara, with active sexual life,
without contraception measures that beginning with pain in abrupt
form at 0900 AM, intense abdominal pain localized to low belly
and that later she becomes with generalized abdominal pain.
The patient was admitted by the emergency room service, 10
hours after the onset of her pain, the patient was in hypovolemic
shock, BP 70-50 mmHg, HR 172 bpm, make a draft, obnubilation,
pallor xxx, acute abdomen, her lab findings RBC 4.2 gr.
With 10% of hematocrit. The abdominal ecosonogram show a
great amount of free fluids into the abdominal cavity and cul de
sac. We began blood, transfusion, we decided to perform a gynecologic
laparoscopic surgery, we found 4 liters of blood in
abdominal cavity, with active bleeding evidence in the left salphinx
by broken ectopic pregnancy. We performed salphinguectomy
with 00 prolene endoloop knot fashion, washed exhaustive
of abdominal cavity, we corroborate complete hemostasia
and we put drainage in placed type penrose in the pelvic hollow.
Results: The patient improve her hemodynamic constants,
two units of globular package were transfused, she tolerate oral
liquids at 48 hours after the surgery and discharge hospital at
the second postoperatively day. Conclusions: The laparoscopic
approach is safe in this type of patients as long as measures
adapted of resuscitation are made, and it is very important to
have all the, laparoscopic equipment ready in order to initiate
an emergency surgery any time with the advantage to avoid postoperatively
adhesions in a nulipara patient that can get to make
difficult a later pregnancy possibility.
V-144
SAFENECTOMÍA ENDOSCÓPICA
Navarrete S, Malavé H, Saab A, Fernández M, Lam R, Lam D.
Hospital Universitario de Caracas. Unidad de Cirugía Laparoscópica,
Servicio de Cirugía II
Objetivo: Describir la técnica mínima invasiva endoscópica con
una sola incisión para el tratamiento del síndrome de insuficiencia
venosa de la safena magna Método: Presentamos la descripción
de la técnica de safenectomía endoscópica en dieciséis
pacientes con insuficiencia de safena magna grados I y II de Hach
quienes fueron intervenidos quirúrgicamente, practicándose una
sola incisión a nivel crural a diferencia de la técnica de recuperación
de safena para puentes coronarios que implica el uso de
dos incisiones. Resultados: Se operaron dieciséis pacientes, 90%
del sexo femenino. Con un tiempo operatorio promedio de 74.6
minutos. Se ligaron un promedio de 3.5 afluentes. Hubo que convertir
un paciente. Dos pacientes (obesos) desarrollaron linfedema
y sólo uno tuvo hematoma. No hubo mortalidad en la serie.
Conclusiones: La safenectomía endoscópica es un procedimiento
Abstract Book
edigraphic.com
39
seguro y efectivo para el tratamiento de la insuficiencia de safena
magna, con óptimos resultados cosméticos.
FP(TL)-145
EMPIEMA PLEURAL EN CONEJOS. MODELO EXPERIMENTAL
PARA ENTRENAMIENTO EN TORACOSCOPIA
Torres R, Marecos C, Orban R, Vagni R, Klappenbach R. Centro de
Entrenamiento e Investigación en Cirugía Toracoscópica y Laparoscópica.
Universidad Nacional del Nordeste. Corrientes, Argentina.
Introducción: La cirugía videotoracoscópica ha demostrado ser
una buena alternativa para el tratamiento de los empiemas pleurales
en los estadios II (fibrino-purulento). El éxito de este procedimiento
está en relación con el entrenamiento y capacitación del
equipo quirúrgico El objetivo de este modelo experimental es lograr
una réplica del empiema pleural del humano en conejos, para
el entrenamiento en cirugía toracoscópica. Material y métodos:
A 20 conejos neozelandeses de 3 y 4 kg se les inyectó en el espacio
pleural- mL de trementina. Ocho horas más tarde, se inyectaron
1010 colonias de Escherichia coli en medio líquido y agar nutriente.
Se administró antibióticos inhibidores de la betalactamasa
por vía parenteral. 96 horas después, utilizando como anestesia
general ketamina 35 mg/kg y acepromacina 0.75 mg/kg e intubación
bronquial selectiva, se les efectuó una toracoscopia. Se colocó
un trócar de 10 mm para la óptica. en el noveno espacio intercostal
a 3 cm de la columna, uno de 5 mm en el sexto espacio a
2.5 cm de la columna y un tercer trócar de 5 mm en el mismo
espacio por fuera del esternón. La técnica toracoscópica consistió
en la aspiración de líquido, remoción de fibrina con pinzas romas,
decorticación y lavado de la cavidad. Se realizó prueba hidroneumónica
para evaluar las lesiones de pleura visceral y se comprobó
la reexpansión pulmonar. Finalizada la cirugía. los animales fueron
sacrificados con inyección letal de tiopental sódico. Resultados:
Todos produjeron un empiema fibrinopurulento similar al del
humano. El uso de cepas bacterianas poco agresivas para el conejo
como la E. coli, permitió la sobrevida de los mismos hasta
finalizar el procedimiento. El antibiótico limitó la infección a la cavidad
pleural. El agar aportó nutrientes necesarios para la duplicación
bacteriana y la trementina actuó como irritante. El modelo
sirvió para reproducir la técnica toracoscópica usada en humanos
para el tratamiento de los empiemas. La cavidad pleural fue pequeña
pero satisfactoria para su manejo por toracoscopia y muy
útil en el entrenamiento de cirujanos pediátricos. Conclusión: Este
modelo experimental en conejos es económico y reproduce fielmente
la fase II del empiema pleural. Permite el entrenamiento
toracoscópico en el manejo de esta patología acortando la llamada
curva del aprendizaje.
FP(TL)-146
TORACOSCOPIC SYMPATHECTOMY PRELIMINARY REPORT
Salinas G, Saavedra L, Sánchez V, Bautista F, León VJ, Orellana
A, Castillo M, Galván P, Campaña MF, Valdivieso A. Maison de
Santé del Sur, San Pablo, San Borja Clinics.
Purpose: Analyze the short term results of the toracoscopic sympathectomy
in the treatment of palmar hyperhidrosis. Methods:
With the patient under general anesthesia, is intubated with a double
lumen tube. The sympathetic chain of the dominant hand is
treated first. Two trocars introduced one 10 mm and one 5 mm.
The lung is collapsed and the T2, T3, T4 ganglia are dissected. A
5 mm clip (hemolock) is placed in the upper portion of T2, the
chain is cut. The rest of the dissected chain is removed with fulguration
of the distal portion. The ganglia is sent to the pathologist.
Results: Since January to November 2003, we have operated on
12 males and 7 females patients with a total of 37 sympathectomies
performed. The response has been 100% successful. One
patient had only side treated and now is complaining of having the
dominant hand dry and the other one completely wet. 70% had

9 TH World Congress of Endoscopic Surgery
transitory compensatory sweating. 0% morbility, 0% mortality. Conclusions:
Toracoscopic Sympathectomy is an excellent technique
for the treatment palmar hyperhidrosis.
FP(TL)-147
DESARROLLO DE HABILIDADES PSICOMOTORAS EN LA EN-
SEÑANZA DE CIRUGÍA ENDOSCÓPICA CON EL USO DE SI-
MULADOR (MÉTODO DE MEDICIÓN)
Sereno TS, Fregoso AJM, Cabrera PC, Ruiz CJ, González OA,
Zermeño RJJ, Orozco AMO, Cumplido HG, Hermosillo SJM.
Antecedentes: La evaluación objetiva de las habilidades psicomotoras
desarrolladas debe ser parte esencial de los programas
de entrenamiento de cirugía endoscópica modernos. Desde hace
tres años se realiza durante un periodo de seis meses, un Curso-
Taller de Cirugía Endoscópica dirigido a residentes y especialistas
quirúrgicos, utilizando simuladores y modelos biológicos. La
finalidad de este trabajo, fue evaluar de forma objetiva mediante
un método de medición, el progreso en las habilidades de los participantes
en la realización de tareas laparoscópicas. Métodos:
Se incluyeron 18 sujetos participantes en el V Curso-Taller de Cirugía
Endoscópica en el Hospital de Especialidades del Centro
Médico Nacional de Occidente del Instituto Mexicano del Seguro
Social. Se diseñó un método de medición que aplicaron los instructores
en dos momentos diferentes: el primer día del curso y
ocho semanas después, tras haber realizado nueve ejercicios distintos
en el simulador. Se midió el tiempo y la precisión con la que
se realizaron cuatro tareas: movilización de objetos, patrón de
corte, sutura y nudos intracorpóreos. Se registraron los tiempos
grupales e individuales promedio tanto basales como finales. Esta
evaluación se aplicó en forma aislada del grupo, a cirujanos laparoscopistas
expertos y a cuatro individuos ajenos al ámbito médico
que funcionaron como grupo control. Resultados: En cuanto a
la movilización de objetos, el tiempo grupal inicial fue de 75 segundos
y el final de 58, la precisión de esta actividad fue de 93%
inicial y 95% al final. El patrón de corte inicial fue 159 segundos y
al final 155 segundos, con una precisión inicial del 77% y 94%
final. Cuando el grupo realizó la aplicación de sutura se cronometraron
210 y 170 segundos respectivamente al inicio y final de la
evaluación con una precisión del 51% en la evaluación basal y
78% en la final. La realización de nudos intracorpóreos fue hecha
por el grupo en un promedio de 214 segundos inicial y finalmente
lo lograron en 90 segundos; la precisión para dicha actividad fue
de 55% al inicio y de 93% al final. Los cirujanos laparoscopistas
expertos hicieron las tareas con mejores tiempos y precisión en
todas las actividades desarrolladas en comparación con los sujetos
a evaluación. Los tiempos y precisión con que se desempeñó
el grupo de estudio tuvieron una mejoría que se reflejó en diferencias
estadísticamente significativas al final del trabajo respecto de
la evaluación inicial; sin embargo nunca superaron a los cirujanos
con mayor experiencia. Conclusiones: Este método de medición
de tiempo y precisión, permite evaluar de manera objetiva el grado
de desarrollo de destrezas quirúrgicas por quienes están aprendiendo
cirugía endoscópica con la implementación de simuladores.
Después de culminar el estudio se definió como alumno
competente a aquel que realizó cada una de las tareas en tiempos
no mayores al 25% y en precisión de al menos 75% de los expertos.
Este método, por su fácil aplicación es reproducible en otras
instituciones.
V-148
SUSTITUCIÓN DE PUERTOS POR AGUJAS PERCUTÁNEAS EN
CIRUGÍA ENDOSCÓPICA
Rivera JMA, Dávila AF, Montero PJJ, Sandoval RJ, Lemus AJ.
Hospital Regional Sesver. Poza Rica, Veracruz, México.
Objetivo: Presentar una nueva modalidad quirúrgica en cirugía
endoscópica con agujas percutáneas de 1 mm de diámetro que
edigraphic.com
40
sustituyen puertos de asistencia en laparoscopia. Introducción:
La cirugía endoscópica es un método de mínima invasión considerado
en algunas patologías quirúrgicas como el estándar de
oro para su resolución. La tendencia en los últimos años a disminuir
el calibre de instrumentos y puertos para optimizar los resultados
de la cirugía laparoscópica tradicional ha dado lugar a la
creación de miniinstrumentos y aditamentos minilaparoscópicos.
Metódos: Las agujas percutáneas (aguja-gancho, aguja pasahilos,
aguja enhebradora, aguja recta atraumática calibre 2-0) sustituyen
de manera eficaz a los puertos de asistencia y algunos
instrumentos en cirugía laparoscópica en diversas patologías (colecistectomía,
apendicectomía, cistectomía ovárica, histerectomía,
salpingectomía, plastia inguinal), cumpliendo con las funciones
de tracción, movilización, disección, ayuda en la colocación de
material de sutura. Las agujas son de acero inoxidable grado
médico, pueden esterilizarce por los métodos habituales en cirugía
endoscópica. Permiten mejorar los resultados estéticos y funcionales
de la cirugía endoscópica tradicional y además reducen
costos. Conclusión: cuando se tiene la experiencia en el uso de
agujas percutáneas en cirugía laparoscópica es posible utilizarlas
sustituyendo puertos de asistencia e instrumentos en algunos
procedimientos endoscópicos, optimizando los resultados estéticos
y funcionales.
V-149
CISTECTOMÍA OVÁRICA POR VÍA LAPAROSCÓPICA CON UN
PUERTO UMBILICAL
López LE, Dávila AF, Montero PJJ, Lemus AJ, Sandoval RJ, Dávila
AU. Hospital Fausto Dávila Solis. Poza Rica, Veracruz, México.
Este trabajo en video muestra la técnica endoscópica con un solo
puerto umbilical para resolver los casos clínicos de quistes benignos
ováricos y paraováricos. El propósito es optimizar los resultados
estéticos y funcionales cuando se compara con la cirugía
laparoscópica tradicional y la cirugía abierta tradicional. La
técnica requiere para su realización: laparoscopio con canal de
trabajo, instrumental de 5 mm en su variedad larga (43 cm) y aditamentos
especiales como agujas percutáneas (aguja-gancho,
aguja-pasahilos). Para la realización de esta técnica es importante
tener experiencia en cirugía laparoscópica, estar familiarizado
con el uso de agujas percutáneas y con el laparoscopio con canal
de trabajo. La técnica está contraindicada en aquellos casos con
sospecha de malignidad. Se muestra como alternativa a la técnica
una variante que se asiste endoscópicamente para puncionar
y exteriorizar el quiste y completar el procedimiento (disección y
ligadura del pedículo vascular) con cirugía abierta tradicional.
Estas técnicas permiten mejorar los resultados estéticos y funcionales
de la cirugía abierta tradicional y de la cirugía laparoscópica
tradicional, además de reducir costos.
V-150
MANEJO LAPAROSCÓPICO DE LOS QUISTES HEPÁTICOS. EX-
PERIENCIA DE 12 CASOS. TÉCNICA QUIRÚRGICA EN QUISTE
DE LOCALIZACIÓN CENTRAL
Acosta LJL, Madrigal SOP, Cabrera AJD.
Antecedentes: Femenina de 56 años de edad originaria del estado
de Morelos. Antecedentes familiares de diabetes mellitus e hipertensión
arterial, cuatro años de presentar hipertensión arterial tratada
con captopril. Niega alérgicos y transfusionales. Padecimiento
actual: Dolor abdominal de 2 años de evolución, relacionado a la
ingesta de todo tipo de alimentos, diagnosticada como gastritis crónica
tx. procinéticos e IBP’S E.F. Sin adenomegalias, no síndrome
pleuropulmonar, hepatomegalia dolorosa a 4-5-3-abajo de borde en
líneas convencionales y masa en área hepática. USG de hígado con
masa ocupativa, quística, única, v. biliar normal. Doppler color, sin
vascularidad, adosada a v. porta y cercanía de la v. cava TAC. Abdominal
masa quística líquida sin cápsula o septos. en segmento 4 y

5 de 12 cm sin dilatar vía biliar intrahepática, vena porta. Bioquímicos
=N. IGg. Equinococo negativa. Descripción de la técnica: Cirugía
el día 22-05-03 programada como destechamiento por vía endoscópica,
mediante 5 puertos, líneas convencionales, lente de 30
grados, punción para obtención de estudio citoquímico, tinción de
Gram, se procede a destechamiento mediante disección, corte y
coagulación monopar de bordes, colecistectomía y revisión biliar.
Colocación de sonda Pezzer para drenaje extracción por un puerto
lateral, con retiro a las 72 horas. USG. Postoperatorio a las 24 hrs
sin colección líquida, 3 meses hígado normal sin cavidad o colecciones.
Boquímicos=N. Comentarios: Es importante determinar en el
preoperatorio la etiología de masas quísticas hepáticas con el fin de
aceptar el destechamiento como manejo quirúrgico de elección la
prueba inmunológica A equinococo deberá ser negativa, también es
importante conocer su localización y estructuras vasculares cercanas
con el fin de evitar accidentes graves, y determinar si existe
patología biliar asociada, en este caso se remarca el manejo de la
vía biliar, la realización de la colecistectomía con el fin de destechar
lo más completa la pared del quiste hepático. A diferencia de quistes
localizados en segmentos periféricos los centrales entrañan un riesgo
mayor. Nuestra experiencia es de 12 casos manejados por vía
endoscópica. Siendo posible realizar el destechamiento en 10 de
ellos y sólo en 2 casos no fue posible de alcanzar por esta vía, los
del segmento 8. Siendo el caso de un quiste calcificado postraumático
y el otro cercano a la vena cava superior, uno se programó para
abordaje por tórax y otro se mantiene en observación. Es factible
realizar el destechamiento en quistes centrales y periféricos. Con
morbilidad baja y mortalidad de 0%. Estancia hospitalaria corta y
bajo costo para la institución.
FP(TL)-151
QUISTE HEPÁTICO NO PARASITARIO.
TRATAMIENTO LAPAROSCÓPICO
Ruiz VA, García AJ, Hernández IJL, Dávila RD, Padilla MCD.
Introducción: Los quistes del hígado se dividen en parasitarios y no
parasitarios. Los no parasitarios son los más frecuentes y se deben
tratar cuando el paciente presenta sintomatología (dolor o datos de
compresión) o complicaciones del quiste. El tratamiento puede ser
mediante drenaje percutáneo o resección de la cápsula del quiste
mediante cirugía abierta o por cirugía laparoscópica. Objetivo: Demostrar
la experiencia del Hospital Juárez de México, en el tratamiento
de los quistes hepáticos no parasitarios, sintomáticos, con
cirugía de mínima invasión. Material y métodos: Se estudiaron seis
pacientes (5 mujeres y 1 hombre), con quiste de hígado diagnosticado
por ultrasonido, en todos se les hicieron pruebas inmunológicas
para descartar que fuera quiste hidatídico. En todos los pacientes se
les resecó la pared del quiste hepático. En dos pacientes en el momento
transoperatorio antes de resecar el quiste, se les realizó escleroterapia
con aplicación de alcohol al 96%, se esperó 10 minutos
antes de efectuar la resección. Resultados: Se pudo realizar la cirugía
laparoscópica en forma satisfactoria en todos los pacientes, no
existió ninguna complicación transoperatoria ni postoperatoria, los
pacientes se egresaron de 2 a 3 días de postoperatorio y en un
seguimiento de 9 meses a 63 meses no se presentó ninguna recidiva,
en el seguimiento clínico y mediante ultrasonografía. Conclusiones:
El tratamiento de mínima invasión para los quistes hepáticos
no parasitarios, debe ser el estándar de oro para su tratamiento,
debido a las ventajas que ofrece este tipo de cirugía en el transoperatorio
y postoperatorio.
FP(TL)-152
LAPAROSCOPIA EN EL DIAGNÓSTICO Y MANEJO DEL ABDO-
MEN AGUDO DE ORIGEN DESCONOCIDO
Quiroz RF, Parra ZR, Jaramillo A.
Objetivo: Evaluar la utilidad de la laparoscopia en el diagnóstico
y manejo del abdomen agudo de origen desconocido. Materiales
Abstract Book
edigraphic.com
41
y métodos: Durante el periodo de Agosto de 1999 a Mayo del
2003, se realizó laparoscopia a pacientes mayores de 15 años
que ingresaron por urgencias a la Clínica Materno Infantil los Farallones
de Cafi, Colombia, con diagnóstico de abdomen agudo
de causa no definida., Se incluyeron en esta serie pacientes con
abdomen agudo posquirúrgico, tanto de cirugía laparoscópica
como abierta, intervenidos por el mismo grupo o remitidos de otra
institución, cuando la causa del abdomen agudo no fue aclarada
previamente. Se excluyeron aquellos pacientes a quienes se les
realizó laparoscopia por abdomen agudo, cuya causa fue establecida
antes del procedimiento. Resultados: Durante el periodo
cumplieron criterios de inclusión 123 pacientes, se obtuvo información
completa en 114 casos. Hombres 34 (30%) y mujeres 80
(70%), la edad promedio fue de 37 altos con rango entre 15 y 84
años. Se hizo el diagnóstico en 112 casos (98.2%), se logró manejar
la causa por vía completamente laparoscópica en 108 casos
(94.7%), sólo en tres casos se convirtió a cirugía abierta. Los
hallazgos incluyeron: apendicitis aguda en 51 pacientes, (edematosa
en l5, con peritonitis localizada en 18, con peritonitis generalizada
en 9 y con plastrón apendicular en 9). Hemoperitoneo en
22 (folículo ovárico sangrante 7, endometriosis 5, embarazo ectópico
roto 3, posquirúrgico 3, quiste ovario roto 2, cuerpo luteo
sangrante 1, menstruación retrógrada l), pelviperitonitis en 9 (salpingitis
7, absceso tubo ovárico 2), adherencias peritoneales 6,
divertículo perforado 5, biliperitoneo poscolecistectomía 4, úlcera
duodenal perforada-peritonitis 2, absceso hepático roto 2, absceso
intraabdominal poscolecistectomía 2, vólvulos de intestino delgado
1, invaginación íleo cólica lipoma de ciego 1, linfoma de
ciego 1, necrosis de apéndice epiploico 1, neumonía basal-peritonismo
1, infección urinaria - peritonismo 1, pancreatitis abscedada
1, perforación de yeyuno - ca. metastásico 1, perforación
sigmoide por colonoscopia 1, esclerosis nodular hepática 1, carcinomatosis
- ascitis 1, adenitis mesentérica 1. Se encontró infección
intraabdominal en 75 (65.80%), 32 (28%) con peritonitis generalizada.
Se presentaron complicaciones en 18 (150%) pacientes,
cinco con absceso intraabdominal, uno se manejó con
antibióticos y a cuatro se les realizó punción drenaje guiada por
escanografía; tres pacientes tuvieron íleo prolongado, una fístula
colocutánea que cerró en 8 días, neumonía en 1, un hematoma
de pared y un hematoma retroperitoneal manejados conservadoramente,
tromboembolismo pulmonar en 1, los dos pacientes de
diverticulitis perforada con peritonitis a quienes no se les intentó
manejo laparoscópico por su mal estado, fallecieron en falla orgánica
múltiple. Conclusiones: El presente trabajo muestra claramente
que este abordaje es técnicamente posible, si se cuenta
con el recurso humano y técnico necesario. Las ventajas en cuanto
a morbilidad, mortalidad, menor impacto en la calidad de vida,
mejores resultados estéticos y reducción de costos globales.
V-153
LAPAROENDOSCOPIC PROXIMAL ESOFAGOGASTRECTOMY
WITH TOTAL SUBSTITUTION OF ESOPHAGUS WITH ANTI-
PERISTALTIC LEFT COLON BY MODERATELY DIFFERENTI-
ATED ADENOCARCINOMA FROM THE GASTROESOPHAGEAL
JUNCTION
Lozada LJD, Contreras AA, Abundez A, Carreto AF. Santa Mónica
Hospital, Cuernavaca, Morelos, México.
Purpose: The objective of this video is to present us the surgical
technique. Material and methods: 43 years old male patient witn
diagnosis of moderated Adenocarcinoma of the gastroesohageal
junction in July 2002, received two cycles of chemotherapy with
etoposido c, 5 fluouracilo and cis platinum and radiotherapy 6000
rads with linear accelerator machine, after a control endoscopic
study in November of 2002 with biopsy reported negative esophagus
to tumor, posteriorly the patient again reinitiates with disphagia,
we repeat the endoscopic study in March of the 2003
finding an exofitic tumor of approx. 3 x 6 cm of gastroesophageal
junction that occludes 70% of the esophagus lumen with

9 TH World Congress of Endoscopic Surgery
histopatologic results of moderately differentiated adenocarcinoma,
the helical toracoabdominal CT scan, reported injury or
delimited to esophagus, without adenomegalias, normal lung and
normal liver, the patient received preoperatively enteral fedding,
previous endotraqueal intubation, balanced general anesthesia,
a diagnostic laparoscopic was made, by fitting subcostal positioning
11-12 mm port, 10-12 mm umbilical port, and 10-12 mm
port to half of the xifoides appendix line and umbilicus scar, and
5 mm port in left flank, we start to review the left colon vascularized
with partial clippage of left colic artery to value suitable collateral
circulation to expenses of marginal artery of drummond,
or serpetin artery, we continue with dissection and liberation of
gastroesphageal junction, gastric fundus, greater and smaller
stomach curvature with surgical stappler and ligasure surgical
device, trashiatal esophageal dissection, trasoperatively endoscopic
for pyloric dilatation with balloon, introduction under direct
vision of saphenotomo, subtotal gastrectomy, incision at level
of left side anterolateral edge of sternocleidomastoideo muscle,
protection of the vascular package, exposure and transection of
cervical esophagus, olive anchorage of safenotomo, stripping
esophaguectomy, liberation of left colon until third means of transverse
colon, ascent and transposition of antiperistaltic left colon,
cologastric anastomosis with Endo GIA 60 stappler, colo rectoanastomosis
with CEEA 28 circular stappler washed of abdominal
cavity, tired test, methylene blue dye test by nasogastric
tubes, positioning of drainage type Jackson Pratt, esophagocolic
anastomosis in neck. Positioning of two pleural tubes 28 and
26 Fr in right hemithorax and finished surgical procedure. Results:
Good postoperatively outcome. Conclusions: We considered
that it is a feasible surgical technique to make by laparoscopic
route when a good colateral circulation is present.
V-154
ALTERNATIVA TERAPÉUTICA DRENAJE ENDOSCÓPICO QUI-
RÚRGICO PARA EL ABSCESO HEPÁTICO AMEBIANO
Nava PC, Reyes EJ, Galicia TM, Moreno CJ, Molina PJ, Perea LH,
Coronado BJ, Sánchez GL, Jiménez LJ. Hospitales Generales 1A,
2A, 47, 194 IMSS. México D.F.
Introducción: Estudio prospectivo multicéntrico lineal efectuado
durante 7 años enero 1996, agosto 2003 se incluyen 13 pacientes,
12 hombres, una mujer todos con indicación para manejo
quirúrgico. Objetivo: Demostrar que la endoscopia quirúrgica
es la mejor alternativa de manejo en pacientes con absceso
hepático amebiano cuando presentan indicaciones de drenaje
tales como falta de respuesta al manejo médico (70%), falla del
manejo con punción guiada, abscesos muy grandes o múltiples
(25%), localizados en la cara posterior del hígado (25%), los
localizados en lóbulo hepático izquierdo (15%), abscesos con
inminencia de ruptura a cavidad peritoneal o comunicación a
órganos vecinos, datos de irritación peritoneal. Material y métodos:
Los pacientes fueron protocolizados mediante clínica,
estudios de USG, TAC, Rx toráx y abdomen, Laboratorio (Bh,
PFH), todos recibieron tratamiento médico previo a base de metronidazol
solo o con cefalosporinas y/o emetina. El drenaje
comprendió identificación, localización, desbridación, aspiración
del contenido, limpieza y legrado del interior del absceso, toma
de biopsia y colocación de drenajes en el interior de la cavidad
del absceso bajo visión directa. Resultados: No se presentaron
complicaciones, se drenaron abscesos de lóbulos derecho
e izquierdo, la cantidad de material (hemático achocolatado) fue
de 200 a 600 cc, estancia hospitalaria de 2 a 5 días. Resultados
excelentes en el 100% de los pacientes. Mortalidad nula, morbilidad
mínima. Conclusiones: Permite visión, exploración y drenaje
directos, se debe considerar como método de elección en
los pacientes con indicación quirúrgica, principalmente en los
centros hospitalarios donde no se cuenta con radiología intervensionista.
edigraphic.com
42
FP(TL)-155
THE UNDERGRADUATE TEACHING OF ENDOSCOPIC SURGERY,
PRESENT AND PERSPECTIVES
Heredia JNM, Escalante PO.
The surgical teaching methods at the undergraduate level, including
the use of the laparoscopic surgery equipment, used at the Medical
Military School are presented, with comments on some historical
aspects, objectives and justification since it’s beginning to present
moment and it’s perspectives for the future. This is a fundamental
concept for the training of military physicians of excellence as required
by the society of the new millenium.
FP(TL)-156
LA VIDEOLAPAROSCOPIA EN LA OCLUSIÓN INTESTINAL
Antozzi M, Zueedyk M, Signoretta A, Jara C, Yoiris A. Hospital Italiano
Regional del Sur, Bahía Blanca, Argentina.
Objetivo: Considerar la laparoscopia como método para diagnosticar
la etiología y tratar las oclusiones intestinales. Métodos: 44
pacientes operados por videolaparoscopia (VLC) por cuadros de
oclusión intestinal desde marzo de 1993 hasta agosto del 2003.
Se analiza la localización y etiología de la oclusión, utilidad de la
VLC para la resolución del cuadro, morbilidad y mortalidad inherentes
al método. Resultados: La oclusión se ubicó en el intestino
delgado en 42 casos (95.5%) y en el colon en 2 oportunidades
(4.5%). Las causas fueron: 23 adherencias, 7 hernias atascadas,
3 tumores, 3 posoperatorios (P.op.) de VLC, 2 cuerpos extraños,
1 P.op. de eventroplastia abdominal, 1 P.op. de histerectomía, 1
eventración abdominal atascada, 1 invaginación intestinal, 1 cáncer
de colon derecho y 1 vólvulo de colon sigmoides. En cuanto a
la utilidad de la VLC el procedimiento fue totalmente laparoscópico
en el 73% de los casos, asistido en el 15.5% y convertido en el
11.5%, llegando al diagnóstico etiológico en el 100% de los casos.
La morbilidad consistió en 2 perforaciones intestinales. No
hubo mortalidad. Conclusiones: La VLC permitió llegar al diagnóstico
etiológico en todos los casos. En el 73% la resolución fue
totalmente VLC. La VLC se muestra como un procedimiento reproducible,
eficaz y seguro para pacientes con sospecha de obstrucción
localizada en el intestino delgado, con baja morbilidad y
nula mortalidad.
FP(TL)-157
EROSIÓN DE LA BANDA GÁSTRICA: ¿SE PUEDE PREVENIR?
Cerón RF, Figueroa AS, Burgos QV.
Introducción: La complicación más, importante que se presenta
después de la colocación de la. banda gástrica ajustable por laparoscopia
para el tratamiento quirúrgico de la obesidad severa,
es la erosión de la banda hacia la luz del estómago, presentándose
en la mayoría de los casos en los primeros 12 meses después
de su colocación, con una frecuencia de 0.5 a 3%. Esta complicación
implica una reintervención para su retiro, y según la experiencia
del cirujano puede ser por laparotomía o por vía laparoscópica.
Y sólo cuando la banda se encuentra erosionada en más
de 80%, se puede retirar por vía endoscópica. Cuando se retira la
banda por erosión, en la mayoría de los casos los pacientes suben
de peso nuevamente, por lo que esta complicación se considera
como fracaso para el tratamiento quirúrgico de la obesidad.
Material y métodos: En el Hospital Reg. Lic. Adolfo López Mateos
del ISSSTE de la Ciudad de México, de mayo de 1998 a agosto
de 2003, se operaron un total de 316 pacientes con banda gástrica
ajustable por laparoscopia como tratamiento quirúrgico de la
obesidad mórbida, 263 (83%) fueron del sexo femenino y 53 (16.71/
1) del sexo masculino, con un promedio de edad de 40.5 años (13
a 68 años) y con IMC de 47 kg/m2 en promedio (37 a 57 kg/m2 ).
De mayo de 1998 a abril de 2002 (47 meses) se operaron 195

pacientes con la técnica de fijación de la banda gástrica, cubriéndola
con 2 puntos seromusculares de estómago-estómago. Y de
mayo de 2002 a agosto de 2003 (15 meses) operamos a 121 pacientes
sin colocación de puntos de estómago-estómago para fijar
la banda. Resultados: En un periodo de 47 meses (de mayo
de 1998 a abril de 2002) fueron operados 195 pacientes, colocando
2 puntos seromusculares de estómago-estómago para fijar la
banda, presentándose 6 casos (3%) de erosión de la banda, todos
los casos se diagnosticaron por endoscopia y serie esofagogastroduodenal
entre 6 y 14 meses después de la cirugía. De
mayo de 2002 a agosto de 2003 (15 meses) operamos a 121 pacientes
sin colocación de puntos seromusculares estómago-estómago
para fijar la banda, sin que hasta el momento se haya presentado
ningún caso de erosión de la banda. A todos los pacientes
se les realizó endoscopia cada 6 meses para descartar la
erosión. Conclusiones: 1. Se ha comprobado que la parte de estómago
que se erosiona, es con la que se cubre la banda. 2. Todas
las técnicas para fijar la banda, descritas hasta el momento
presentan un índice de erosión del 0.5 al 3%.,3.- Con la técnica
de no colocar puntos seromusculares de estómago-estómago para
fijar la banda descrita por nuestro grupo, después de 15 meses de
seguimiento no se ha presentado ningún caso de erosión. 4.- Con
esta técnica no se ha presentado ningún caso de deslizamiento.
5.- Es importante el seguimiento a largo plazo para demostrar que
con esta técnica no se presentará erosión de la banda.
FP(TL)-158
MANEJO LAPAROSCÓPICO DE LEIOMIOMAS ESOFÁGICOS
Esquivel PP, Kettenhofen EW, Berrones GD, Jiménez EJL, Aguascalientes,
México.
El uso de cirugía laparoscópica para el tratamiento quirúrgico
de las enfermedades benignas de esófago es actualmente bien
establecido y altamente confirmado por diversos reportes a nivel
mundial. Durante 12 años de cirugía endoscópica de esófago
se han realizado más de 650 procedimientos, la mayor parte
de ellos para el tratamiento de la enfermedad por reflujo gastroesofágico.
La presencia de tumores esofágicos benignos es
poco frecuente, y la mayor parte de ellos pasa inadvertido en la
mayor parte de los pacientes. El hallazgo transoperatorio de un
leiomioma puede ser la mayor detección de estos tumores. La
mayoría no requiere manejo ni extirpación. En el presente trabajo
se reportan 3 casos de leiomiomas detectados durante el transoperatorio
de cirugía esofágica y el tratamiento laparoscópico
de un leiomioma que estenosaba la mayor parte de la luz esofágica,
causando disfagia importante. El cirujano que realiza cirugía
esofágica tiene que estar familiarizado con la morfología de
este tipo de tumoraciones, su evolución clínica y en tener experiencia
para el manejo laparoscópico cuando las dimensiones
de la tumoración lo indiquen.
FP(TL)-159
FUNDUPLICATURA DE NISSEN POR LAPAROSCOPIA. EXPE-
RIENCIA DE 350 CASOS SIN LIBERACIÓN DE GÁSTRICOS COR-
TOS
Alcaraz HM, Cabazos MA, Reyes H, Aranda A, Álvarez G, Fraga H.
Departamento de Cirugía General, Hospital Christus Muguerza Monterrey.
La relación entre reflujo gastroesofágico (RGE) y esofagitis no fue
bien reconocida hasta finales de los 40s. En el año de 1951 Allison
describió el primer procedimiento exitoso para el manejo de la enfermedad
por RGE y el cual consistía en la reducción de los pilares
y el cierre de la crura. No fue hasta el año de 1956 cuando Nissen
describe una técnica antirreflujo exitosa consistente en la funduplicación
a 360°, obteniendo con este procedimiento resultados alentadores.
Presentamos nuestra experiencia de 350 casos de ERGF
tratados quirúrgicamente con funduplicación de 360° sin libera-
Abstract Book
edigraphic.com
43
ción de vasos gástricos cortos, cierre de pilares y fijación de manguito.
Esta casuística abarca un periodo de tiempo de 10 años a
la fecha. El 64% (224 casos) de nuestra población fue del sexo
femenino y la edad promedio fue de 42.6 + 9.8 años con un rango
de 19 a 71 años. Todos los pacientes fueron estudiados con endoscopia
superior, en el 96.5% de los casos (338 pacientes) se
contó con estudios de manometría preoperatorio y en el 16% (56
pacientes) con phmetría veintiocho, seis pacientes (7.42%) fueron
diagnosticados como Barret durante su evaluación endoscópica.
Observamos disfagia clínicamente significativa y persistente
en 6 casos (1.71%), tres de estos mejoraron con dilataciones
esofágicas (mejoría total en dos y persistencia ocasional de los
síntomas en una paciente), los restantes tres pacientes requirieron
reintervención quirúrgica (uno de ellos se diagnosticó ulteriormente
como esclerodermia y en dos por deslizamiento del manguito).
Nuestro grupo realiza de forma rutinaria la funduplicatura
de 360° sin liberación de gástricos cortos y aún en pacientes con
trastornos leves de la motilidad esofágica. La estandarización
de esta técnica nos ha permitido la reducción importante en los
tiempos quirúrgicos (procedimientos hasta de 17 minutos) con
buenos resultados clínicos y morbilidad comparablemente menor
a la reportada en la literatura internacional.
V-160
RESULTADOS DE NUEVE AÑOS DE EXPERIENCIA EN EL MA-
NEJO ENDOSCÓPICO QUIRÚRGICO DE ERGE
Nava PC, Reyes EJ, Galicia TM, Moreno CJ, Molina PJ, Perea LH,
Coronado BJ, Sánchez GL. Hospitales Generales 1A, 2A, 30A, 47,
194 IMSS. HG Homeopático SS. México, D. F.
El manejo endoscópico de ERGE presenta claras ventajas sobre
la cirugía tradicional. Nuestro equipo realiza este procedimiento
desde hace 9 años, asesorados inicialmente por cirujanos nacionales
endoscopistas de reconocido prestigio internacional, el proceso
ha sido lento pero gratificante con bajos índices de complicaciones.
Es un estudio multicéntrico de 353 pacientes entre mayo
de 1994 y agosto de 2003, sometiéndose a cirugía endoscópica
con los siguientes criterios: sintomatología mayor de 12 meses,
sin mejoría a pesar de tratamiento médico, datos clínicos y endoscópicos
de esofagitis, SEGD y endoscopias positivas, manometría
y pHmetría. Técnica: en 88% se usó técnica Nissen con
cierre de pilares; 6% Toupet; 3% técnica en “V” y 3% hemifunduplicatura;
el promedio de estancia intrahospitalaria fue de 24 hrs,
inicio de vía oral 8 hrs, tiempo quirúrgico inicial 3 hrs, actualmente
1.50 hrs considerando que son hospitales de adiestramiento;
incapacidad laboral 7 días. Hubo seis perforaciones esofágicas
transoperatorias, 2 por periesofagitis severa, 3 al paso de la sonda
de calibración y 1 anclaje inadvertido de SNG, de éstas, 2 se
repararon durante el mismo evento quirúrgico y 4 fueron convertidas
para su reparación; 5% cursaron con disfagia y reflujo recurrentes
por más de tres meses que cedieron con dilatación esofágica
endoscópica y tratamiento médico. Se observaron buenos
resultados en el 93%, actualmente sólo se hace seguimiento del
60%. Conclusiones: Se demuestra la seguridad y eficacia de la
técnica, los mejores resultados con Nissen-Rossetti, inicio temprano
de vía oral (12 hrs), alta hospitalaria en 24 hrs, mortalidad
nula, morbilidad mínima, uso de analgésicos y antimicrobianos
por 24 hrs y retorno a la vida normal en 7 días.
FP(TL)-161
RESULTADOS DE LA FUNDUPLICATURA TIPO NISSEN EN EL
MANEJO DE LA ENFERMEDAD DE BARRET
Vázquez SJH, Arenas EG, Padilla AJM, Ayala ZJ, Castañeda RCA,
González AMA, Torre SC, Ayala MJS, Torres SC, Ayala MJL.
Uno de los tumores más letales que existen es el adenocarcinoma
del esófago. En México es poco frecuente y no se tienen cifras
exactas, su frecuencia se considera menor al 1% de todos

9 TH World Congress of Endoscopic Surgery
los tumores malignos del tubo digestivo. Los reportes muestran el
incremento de esta enfermedad en el mundo Occidental y existe
una necesidad urgente de encontrar un método eficaz que permita
vigilar y prevenir el adenocarcinoma esofágico, que surge en su
gran mayoría a partir de una enfermedad premaligna reconocida
como la metaplasma de Barret. Existen factores ambientales, locales
y características predeterminadas genéticamente que interactúan
en la evolución de la enfermedad. El riesgo para desarrollar
un adenocarcinoma esofágico en los pacientes con esófago
de Barret es de 30 a 125 veces mayor que el resto de la población.
El presente estudio muestra la evolución de 72 pacientes, en el
periodo de enero de 1992 a diciembre de 1993, diagnosticados
con esófago de Barret mediante endoscopia y biopsia, tratados
quirúrgicamente con funduplicatura de 360º tipo Nissen por cirugía
de mínima invasión en el Hospital Regional “General Ignacio
Zaragoza” del ISSSTE, en la ciudad de México, D.F. El objetivo
del presente estudio es valorar la evolución del paciente con esófago
de Barret sometido a tratamiento quirúrgico, y analizar si el
procedimiento disminuye el riesgo de evolución a adenocarcinoma.
El seguimiento postoperatorio se realiza cada 3, 6 y 12 meses
por los servicios de endoscopia, cirugía general y anatomopatología.
En el presente estudio sólo un caso de los pacientes tratados
quirúrgicamente desarrolló adenocarcinoma del esófago a los 6
años y 7 meses de operado. Se presenta el protocolo de estudio
de esos pacientes, la técnica quirúrgica empleada y los procedimientos
agregados realizados en estos casos, así como una comparación
con los resultados obtenidos de 9 pacientes que no fueron
tratados quirúrgicamente, en donde 3 casos desarrollaron adenocarcinoma
de esófago.
FP(TL)-162
FUNDUPLICATURA LAPAROSCÓPICA EN PACIENTES CON EN-
FERMEDAD POR REFLUJO GASTROESOFÁGICO Y ESÓFAGO
HIPOCONTRÁCTIL: ¿FUNDUPLICATURA TOTAL O PARCIAL?
Rendón CE, Hernández CA, Villanueva SKR, Huizar SP, Mata QC,
Dorado RJD, Martínez JA.
Introducción: Los pacientes con esófago hipocontráctil secundario
a enfermedad por reflujo gastroesofágico (ERGE) tienen
más probabilidad de presentar disfagia después de una funduplicatura
total (tipo Nissen) en comparación con una parcial (tipo
Toupet). Objetivo: Demostrar que la funduplicatura laparoscópica
tipo total (Nissen) no presenta mayor grado de disfagia en
pacientes con ERGE y esófago hipocontráctil. Material y métodos:
El presente es un estudio descriptivo, retrolectivo, longitudinal
que incluyó a los pacientes con diagnóstico de ERGE y esófago
hipocontráctil sometidos a funduplicatura laparoscópica. Se
registraron: demografía, tipo de funduplicatura (Nissen o Toupet),
grado de disfagia al mes, a los 3, 6 y 12 meses. Resultados: Se
incluyeron 301 pacientes. Se dividieron en dos grupos de acuerdo
al tipo de funduplicatura: Grupo Nissen = 201 p (66.5%), 123
hombres y 78 mujeres, con un promedio de edad de 47 ± 8 años.
Grupo Toupet = 100 p (33.5%), 71 hombres y 29 mujeres con un
promedio de edad de 51 ± 11 años. El tiempo quirúrgico promedio
en el Grupo Nissen en comparación con el Grupo Toupet fue
de 75 min ± 12 min vs 45 min ± 11 min. En el Grupo Nissen hubo
mayor grado de disfagia al primer mes: grado I = 44, grado II =
103, grado III = 54, comparado con el Grupo Toupet: grado I =
89, grado II = 11, grado III = 0. Sin embargo, al tercer mes ambos
grupos tuvieron resultados similares: Grupo Nissen: grado I = 104,
grado II = 12, grado III = 0; Grupo Toupet: grado I = 12, grado II =
3, grado III = 0. El resto de los pacientes no presentaron disfagia.
El control del reflujo gastroesofágico pirosis/regurgitación)
fue en el 100% de los pacientes desde el primer mes del posoperatorio.
Del sexto mes en adelante ningún paciente presentó disfagia.
Se reportan a 3 pacientes con enfisema subcutáneo, el
cual se resolvió espontáneamente a las 24 horas. Conclusiones:
Tanto la funduplicatura tipo Nissen como la funduplicatura
tipo Toupet controlan satisfactoriamente el reflujo gastroesofá-
edigraphic.com
44
gico. Se demuestra además que la funduplicatura tipo Nissen en
pacientes con esófago hipocontráctil se puede realizar con seguridad,
ya que la disfagia desaparece al tercer mes del postoperatorio
teniendo así resultados similares con la funduplicatura
tipo Toupet.
FP(TL)-163
ACALASIA: SIEMPRE PRESENTA UN ESFÍNTER ESOFÁGICO
INFERIOR HIPERTÓNICO?
Castro RJM, Trabanino PMA, López AME, Rodríguez BG.
Introducción: La acalasia es un trastorno motor primario con una
incidencia de 1/400, 000, el método estándar de oro de diagnóstico
es ausencia de relajación del esfínter esofágico inferior (EEI) (presión
residual > 8 mmHg) y ausencia de peristalsis. Sin embargo no
en todos los casos el esfínter es hipertenso, ya que puede ser normal
o incluso hipotónico. Se presentan los hallazgos manométricos
de pacientes con acalasia en un centro de concentración de
estudios manométricos. Objetivo: Analizar los hallazgos manométricos
de los pacientes con diagnóstico de acalasia corroborado por
este método y determinar qué pacientes tuvieron un esfínter esofágico
inferior hipotónico o normotónico. Método: Es un estudio retrospectivo,
transversal y descriptivo, basado en las manometrías
esofágicas realizadas en el periodo de enero del 2000 a diciembre
del 2003, con el diagnóstico de acalasia. Se analizaron las variables
socio-demográficas, presión del EEI (Nl: 14-45 mmHg), relajación,
presión residual y motilidad del cuerpo esofágico. Todos los
casos fueron realizados con catéter de perfusión o de estado sólido
con un polígrafo y un programa de la marca Synetics. Resultados:
Presión del EEI Pacientes (%)
Hipotónico 8 (14%)
Normotónico 34 (61%)
Hipertónico 14 (25%)
Total: 56 (100%)
Conclusión: La manometría esofágica es el estándar de oro para
el diagnóstico de acalasia, la hipertonía del EEI no es un criterio
diagnóstico ya que la presión puede ser normal o baja y en esta
serie lo más frecuente fue normotónico, los criterios de diagnóstico
absolutos son ausencia de relajación y aperistalsis del cuerpo esofágico,
la frecuencia de acalasia vigorosa es muy baja, similar a la
reportada en la literatura mundial, en nuestra serie fue de 3 casos
que representa el 0.5%.
FP(TL)-164
FUNDUPLICATURA LAPAROSCÓPICA SIMPLIFICADA: RESUL-
TADOS DE 302 CASOS
Rendón CE, Hernández CA, Villanueva SKR, Huizar SP, Mata QC,
Dorado RJD, Martínez JA.
Introducción: La enfermedad por reflujo gastroesofágico (ERGE)
es un problema de salud significativo que afecta a gran parte de la
población. La cirugía antirreflujo laparoscópica juega un papel importante
en el control de la enfermedad por reflujo en pacientes
bien estudiados, considerado hoy como el tratamiento idóneo. Objetivo:
Describir la experiencia de funduplicatura laparoscópica en
pacientes con ERGE en el Centro de Endoscopia Quirúrgica Gastrointestinal.
Material y métodos: Es un estudio descriptivo, retrolectivo
y longitudinal. Se revisaron expedientes de pacientes
con ERGE candidatos para cirugía antirreflujo. Todos los pacientes
fueron estudiados por valoración clínica, endoscopia y biopsia,
manometría, y sólo en casos seleccionados con serie esofagogástrica
y phmetría/24 h. La técnica utilizada fue la siguiente:
disección roma del hiato, hiatoplastia con un solo punto, sin sec-

ción de vasos cortos, y funduplicatura de 3 cm de longitud. Resultados:
En un periodo comprendido de 1996 a 2003, se analizaron
302 casos de pacientes con diagnóstico de ERGE, 187 hombres
y 115 mujeres, con edad promedio de 46 años. El tiempo
promedio de evolución de la enfermedad fue de 2.5 años, los hallazgos
endoscópicos más frecuentes fueron: hernia hiatal, esofagitis
grado II, y enfermedad ácido péptica (p = 204, 67.5%). El
esófago de Barret se encontró en 27 p (8.9%) de éstos, 11 p (46%)
tuvieron displasia de bajo grado. El hallazgo manométrico más
frecuente fue: esfínter esofágico inferior hipotenso y esófago hipocontráctil
(62.5%). Se realizaron 201 funduplicaturas Nissen,
100 tipo Toupet y 1 procedimiento de Hill. Se presentaron 14 complicaciones
(4.6%), 13 de las cuales fueron por enfisema subcutáneo
resuelto espontáneamente, y una hemorragia de un vaso
corto resuelto por colocación de grapas. No se reporta mortalidad.
Conclusión: En pacientes con ERGE la cirugía antirreflujo
controla la sintomatología (pirosis/regurgitación) en la mayoría de
los casos a corto y largo plazo, con baja morbilidad y nula mortalidad,
haciendo de este procedimiento el tratamiento idóneo.
V-165
EXOFAGOPEXIA POSTERIOR CON HEMIFUNDUPLICATURA
ANTERIOR POR LAPAROSCOPIA, UNA NUEVA TÉCNICA QUI-
RÚRGICA PARA EL TRATAMIENTO DEL ERGE
Olguín J, Peña L, Pardiñaz M. Hospital Ángeles del Pedregal.
Con el paciente en posición europea, se realiza neumoperitoneo
cerrado con aguja de Veres, colocando 4 puertos (2 de 10 mm y 2
de 5 mm), en abdomen superior, colocando separador de hígado,
iniciamos la disección del ligamento gastrohepático, respetando la
rama hepática del vago, continuando con la membrana freno esofágica,
identificando el pilar derecho e izquierdo, se diseca el esófago
posterior por debajo del vago, de derecha a izquierda, terminando
la disección meticulosa del hiato, liberando al esófago completamente
y conservando el ligamento gastrofrénico. Se cierran
los pilares con prolene 0 (2-3 puntos), se fija el esófago al pilar
derecho con 2 puntos de prolene 0 donde se alinea a éste (ESO-
FAGOPEXIA). Se procede a acentuar el ángulo de His con un punto
que va de fundus gástrico al ligamento medio (del hiato), a esófago
cara anterolateral izquierda (respetando el vago anterior) y
nuevamente al fundus. Se completa hemifunduplicación anterior
(220 grados) con dos a tres puntos de fundus a borde externo del
pilar derecho (zona aponeurótica entre éste y la cava) formando un
manguito de 4 cm. Se termina el procedimiento.
FP(TL)-166
ESTUDIO COMPARATIVO COSTO-BENEFICIO, ENTRE LA CIRU-
GÍA LAPAROSCÓPICA Y CONVENCIONAL, EN EL SERVICIO DE
URGENCIAS DEL HOSPITAL GENERAL DE MÉXICO
Montalvo JE, Athié C, Guizar C, Gutiérrez VR, Fernández HE, Basurto
E, González V, Zavala J, Cárdenas O. Servicios de Urgencias
Médico Quirúrgicas y Cirugía General, Hospital General de México.
Departamento de Cirugía, Facultad de Medicina, UNAM.
Introducción: La cirugía endoscópica es el “estándar de oro”
para procedimientos quirúrgicos que anteriormente eran realizados
por el método convencional o “abierto”, tanto en intervenciones
electivas y/o de urgencia. Actualmente se aplica rutinariamente,
como ejemplo: en patologías agudas de la vesícula
biliar, dado los costos y beneficios aún se encuentra en controversia
su aplicabilidad en instituciones especialmente públicas,
como método de tratamiento definitivo, por tal motivo se realizó
el presente estudio de análisis costo beneficio en el tratamiento
de urgencia de los casos de patología vesicular. Material y métodos:
Estudio clínico, prospectivo, doble ciego, comparativo y
longitudinal, realizado en los servicios de Urgencias Médico
Quirúrgicas y Cirugía General del Hospital General de México
(HGM), se incluyeron un total de 200 casos de pacientes con
Abstract Book
edigraphic.com
45
patología aguda de vesícula biliar, 104 casos fueron intervenidos
por el método convencional y 96 por vía laparoscópica, en
el periodo de septiembre del 2000 a diciembre del 2002. Todos
los casos tuvieron el cuadro clínico y diagnóstico de litiasis vesicular
confirmado por US y corroborado por estudios de laboratorio.
Se estudiaron las siguientes variables: costos totales y parciales
de los dos métodos estudiados, días estancia, complicaciones,
tiempo quirúrgico, personal de salud asignado, material
y equipo empleado, etc. según indicadores de un hospital de
tercer nivel de atención en la ciudad de México. Resultados:
Fueron ingresados al estudio previo consentimiento informado,
173 pacientes del sexo femenino y 27 del sexo masculino. Las
variables estudiadas como días estancia (promedio 1.5 ± .5) y
tiempo quirúrgico (56 min ± 12 min) fueron menores por la vía
endoscópica, existiendo diferencias estadísticamente significativas
en comparación con el método convencional, en relación a
costos totales, complicaciones y personal empleado comparando
ambos procedimientos no hubo diferencias estadísticas. Debemos
mencionar que en el HGM, existe un costo extra es de:
U$ 500.00 (donativo solicitado para ser intervenido quirúrgicamente
por vía endoscópica, además de los insumos regulares).
Conclusiones: En una institución de tercer nivel de atención en
el Distrito Federal, como lo es el HGM, el presente estudio de
costo beneficio, nos indica que la atención urgente del paciente
con patología vesicular, es altamente recomendable realizarlo
por vía endoscópica, la inversión inicial en la adquisición del
equipo y control adecuado del material e insumos, en comparación
al método convencional o “abierto”, es muy similar, sin diferencias
estadísticas, sin embargo los costos por vía endoscópica
disminuyen progresivamente de acuerdo al número de pacientes
intervenidos y experiencia del equipo quirúrgico.
FP(TL)-167
LAPAROSCOPIC SURGERY IN COMPLICATED INFLAMMATORY
BOWEL DISEASE
Mans E, Delgado S, Panés J, Momblán D, Estrada O, Piqué JM,
Lacy AM. Gastrointestinal Surgery, Institute of digestive disease,
Hospital Clinic, University of Barcelona, Spain.
Introduction: The use of laparoscopic approach in patients with
inflammatory bowel disease (IBD) is still controversial. Advantages
related to laparoscopy could be important in this type of patients:
better cosmetic results, less inflammatory response and
less adhesions. AIM: To analyze the results of laparoscopic surgery
in the treatment of IBD. Methods: Prospective analysis between
January 2001 and April 2003. Fifty-two patients with the
diagnosis of IBD were operated using laparoscopic approach: 36
patients with Crohn’s disease (CD) and 16 with Ulcerative Colitis
(UC). All CD patients were operated by elective basis. Indications
for surgery were: 63.8% stenotic disease and 36.2% presented
with fistula disease. Eleven patients with UC were operated by
urgent basis. Results: Mean age was 24 years for CD and 32 for
UC. Nineteen percent of patients with UC and 75% of patients
with UC had previous abdominal surgery. The most frequent operation
in UC patients was laparoscopically assisted total colectomy
with end ileostomy, completing posteriorly the proctocolectomy
with ileal-anal “J” pouch with or without diverting ileostomy.
Conversion rate was 12.5% due to hypercarbia and one ureteral
lesion. Mean operative time was 210 minutes and postoperative
complication rate was 11.1%. Mean hospital stay was 5.38 days.
In CD patients, the most frequent intervention was laparoscopically
assisted resection of a previous ileotransversostomy and ileocecal
resection. Conversion rate was 16.6% due to a marked
inflammatory reaction that difficulted the dissection. Mean operating
time was 126 minutes and postoperative complication rate was
13.8%, two of them required reintervention. Mean hospital stay
was 5.43 days. Conclusion: This results suggests that laparoscopic
surgery in patients with IBD is a safe and feasible option,
even in patients with previous abdominal conventional surgery.